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DISEASES 



OF THE 



EAR, NOSE AND THROAT 

MEDICAL AND SURGICAL 

BY 

Wendell Christopher Phillips, M.D. 

Professor of Otology, New York Post-Graduate Medical School and Hospital; Surgeon to 

the Manhattan Eye, Ear and Throat Hospital; Fellow and Ex-President of the 

American Laryngological, Rhinological and Otological Society; Fellow of the 

American Otological Society; Fellow of the American Academy of 

Ophthalmology and Otolaryngology; Member of the New York 

Otological Society; Attending Otologist to the Post- 

Graduate Hospital and Babies' Wards; President 

of the Medical Society of the State of 

New York, etc., etc. 

FOURTH REVISED EDITION 



Illustrated with 566 HaIf=tone and Other Text Engravings, Many of them 
Original; Including 38 Full=page Plates, Some in Colors. 




PHILADELPHIA 

A. DAVIS COMPANY, Publishers 

English Depot 
Stanley Phillips, London 

1917 






COPYRIGHT, 1911 
COPYRIGHT, 1913 
COPYRIGHT, 1915 
COPYRIGHT, 1917 

BY 

F. A. DAVIS COMPANY 
Copyright, Great Britain. All Rights Reserved 



OCT 291317 



Philadelphia, Pa., U. S. A. 

Press of F. A. Davis Company 

1914-16 Cherry Street 



©CU476828 



PREFACE TO FOURTH EDITION. 



*' 



In presenting the Fourth Edition of this textbook, I desire to 
express my grateful appreciation of the generous support accorded by 
my confreres, especially the teachers of oto-laryngology, by medical 
students, and the medical profession in general. 

Its adoption as the standard textbook by the majority of the Medi- 
cal Schools of the country, together with the rapid exhaustion of the 
Third Edition, has encouraged me to revise the subject-matter in many 
particulars, and to add several items of new arid up-to-date material. 

Especially has it been my desire to thoroughly Americanize this 
volume, by giving preference to the achievements of American otolo- 
gists, rhinologists, and laryngologists. 

In line with this idea, I have eliminated the former chapter on 
Suspension Laryngoscopy and have introduced a new chapter upon this 
topic, illustrated with the Lynch instruments. 

I have also given a plain statement of the present status of the 

Hay Fever problem, commented upon the suction treatment of Nasal 

Accessory Sinus affections, and I have amplified the text relating to 

Ozena, the treatment of the diseased tonsil in adults, etc. 

W. C. P. 

40 West Forty-seventh Street, 
New York City. 



(iii) 



PREFACE. 



In the preparation of this volume it has been my conscientious 
endeavor to define the essential features of the principal diseases of 
the ear, nose and throat, and to outline the modern and approved 
methods of treatment for these affections. 

The work was attempted, in part, in response to repeated 
requests from many students and practitioners of medicine whom I 
have been privileged to instruct in the New York Post-Graduate 
Medical School and at the Manhattan Eye, Ear and Throat Hospital 
during" the past twenty years. Hence, it has been prepared to meet 
the needs of the general practitioner and surgeon as well as the 
otologist and laryngologist. 

I have purposely refrained from perpetuating discarded theories, 
or descriptions of operations which are either obsolete or have been 
superseded by more modern methods, simply for the purpose of 
completing the record or to conform to the older text-books. N*or 
have I introduced modern theories or operations unless they possess 
a reasonable measure of scientific value. In short my purpose has 
been to write a practical, accurate and concise treatise bearing the 
approval of personal experience. 

In the chapters devoted to general considerations I have 
grouped various symptoms and measures of treatment which are 
common to two or more affections, in order to avoid needless repeti- 
tion. A section devoted to the influence of general diseases and 
conditions upon the ear, nose and throat has permitted the grouping 
of a variety of affections (numbering about thirty-seven), which 
exhibit symptoms or lesions referable to these organs, and to 
depict the necessary local and general measures of treatment for the 
same. It is believed that this section will appeal to the general 
practitioner and be valuable for reference. I have purposely placed 
the section on the ear first in order to give emphasis to the fact that 
in this book the space devoted to the ear is not a mere addendum, 
but a complete work on otology. The section on the nose and 
throat is at the same time equally comprehensive and complete. 

The subject-matter is presented in the general form of a text- 
book, but in the preparation of the text as well as the illustrations I 
have aimed to make it a practical, comprehensive operative surgery 
(iv) 



PREFACE. v 

of the ear, nose and throat. To this end the illustrations of opera- 
tions or steps of operations, whether schematic or actual, are 
accurate and may safely serve as guides to the surgeon. 

It is a pleasure to acknowledge the aid received from the pub- 
lications of my numerous confreres. The standard American and 
foreign text-books, monographs and published articles have been 
freely consulted, and many of these have been referred to in the text. 
Parker's excellent classification of the diseases of the pharynx and 
larynx has been adopted in part. 

I desire also to express my sincere thanks for the encouragement 
and many courtesies extended by my colleagues .in New York and 
elsewhere, many of whom have been personally consulted regarding 
numerous phases of this work. The members of my staff at the 
Manhattan Eye, Ear and Throat Hospital have responded cheerfully 
to all requests for assistance in various details. I am specially 
indebted to Drs. S. J. Kopetzky, J. J. Thomson, L. M. Hubby, E. P. 
Fowler, J. H. Guntzer and L. J. Denchfield for outlining or com- 
piling various items of descriptive matter, and for abstracting 
valuable material from foreign and American literature. Mr. K. K. 
Bosse has devoted his best energies and skill to the preparation of 
the numerous drawings. The valuable assistance rendered by Miss 
B. Arnaud in attending to the various minor details is gratefully 
acknowledged. 

My thanks are due to the publishers for their valuable sugges- 
tions and for the care bestowed upon the numerous details pertain- 
ing to the mechanical preparation of this work. 

W. C. P. 

40 West Forty-seventh Street, 
New York City. 



CONTENTS. 



Part I. The Ear. 
Section I. — General Considerations. 

CHAPTER. PAGE. 

I. The Office Equipment 1 

II. The Examination of Patients 8 

III. The Physiology of Hearing 24 

IV. Functional Examination. The Tests for Hearing 34 

V. General Etiology of Ear Diseases 41 

VI. General Symptomatology of Ear Diseases 50 

VII. General Diagnosis of Ear Diseases 61 

VIII. General Therapy of Ear Diseases 80 

Section II. — The External Ear. 

IX. Surgical Anatomy of the External Ear 103 

X. Diseases of the External Ear 108 

XI. Diseases of the External Ear (Continued) 124 

XII. Diseases of the External Ear (Continued). Malformations and 

Anomalies 142 

XIII. Diseases of the External Ear (Continued). Neoplasms 151 

Section III. — The Middle Ear. 

XIV. Diseases of the Middle Ear. Diseases and Injuries of the 

Membrana Tympani 167 

XV. Diseases of the Middle Ear (Continued ). Surgical Anatomy of 

the Middle Ear and Eustachian Tube 173 

XVI. Diseases of the Middle Ear (Continued). Classification. Acute 

Middle-ear Catarrhs 181 

XVII. Diseases of the Middle Ear (Continued ) . Chronic Middle-ear 

Catarrhs 186 

XVIII. Diseases of the Middle Ear (Continued). Acute Inflammation 

of the Middle Ear and Mastoid Process 196 

XIX. Diseases of the Middle Ear (Continued). Acute Diseases of 

the Mastoid Process 210 

XX. Diseases of the Middle Ear (Continued ) . The Simple Mastoid 

Operation 225 

XXI. Diseases of the Middle Ear (Continued). Chronic Purulent 

Otitis Media 253 

XXII. Diseases of the Middle Ear (Continued). The Radical Mastoid 

Operation 279 

XXIII. Complicating Lesions of Purulent Otitis Media. Purulent 

Labyrinthitis 312 

(vi) 



CONTENTS. 



CHAPTER. 
XXIV. 



XXV. 



XXVI. 



PAGE. 

Complicating Lesions of Purulent Otitis Media (Continued). 

The Intracranial Complications of Purulent Otitis Media 

Lateral Sinus Thrombosis . . 344 

Complicating Lesions of Purulent Otitis Media (Continued). 

Intracranial Complications. Otitic Diseases of the Meninges. 364 
Complicating Lesions of Purulent Otitis Media (Continued). 

Otitic Brain Abscess 374 



Section IV. — Diseases of the Perceptive Apparatus and Miscellaneous 
Diseases and Conditions of the Ear. 



XXVII. Diseases of the Perceptive Apparatus. Otosclerosis 
XXVIII. Miscellaneous Otitic Conditions 



385 
393 



Part II. The Influence of General 'Diseases upon the 
Ear, Nose and Throat. 

XXIX. The Influence of General Diseases upon the Ear, Nose and 

Throat. Introduction. Tuberculosis. Lupus 406 

XXX. The Influence of General Diseases upon the Ear, Nose and 

Throat (Continued). Syphilis 432 

XXXI. The Influence of General Diseases upon the Ear, Nose and 

Throat (Continued). Diphtheria. Scarlatina. Measles .. 449 
XXXII. The Influence of General. Diseases upon the Ear, Nose and 

Throat (Continued). Typhoid Fever, Typhus Fever, etc. . 472 



Part III. The Nose and Accessory Sinuses. — The 
Pharynx and Fauces. — The Larynx. 

Section I. — The Nose and the Nasal Accessory Sinuses. 

XXXIII. Acute Inflammatory Affections of the Nasal Mucosa 491 

XXXIV. Chronic Inflammatory Affections of the Nasal Mucosa 501 

XXXV. The Nasal Septum and its Pathological Conditions 518 

XXXVI. The Turbinate Bones and their Diseases 546 

XXXVII. The Diseases of the Nasal Accessory Sinuses. Anatomical 

Classification. The Maxillary Antrum 566 

XXXVIII. The Diseases of the Nasal Accessory Sinuses (Continued). The 

Frontal Sinuses 587 

XXXIX. The Diseases of the Nasal Accessory Sinuses (Continued). 

The Ethmoidal Sinuses and the Sphenoidal Sinuses 609 

XL. The Correction of External Nasal Deformities, Epistaxis, 
Foreign Bodies in the Nose, Parasites (Maggots, Screw- 
worms, Fungi, etc.), Rhinoliths, Nasal Furunculosis 629 

XLI. Nasal Neuroses ' 641 

XLIT. Neoplasms of the Nose 651 



CONTENTS. 



CHAPTER. 
XLIII. 



XLIV. 



XLV. 



XLVI. 



XLVII. 



Section II. — The Pharynx and Fauces. 

PAGE. 

Diseases of the Nasopharynx. Surgical Anatomy. Acute Naso- 
pharyngitis. Simple Chronic Nasopharyngitis. Atrophic 
Nasopharyngitis. Adenoids. Neoplasms. Foreign Bodies. 661 

Diseases of the Oropharynx. Surgical Anatomy. Malforma- 
tion and Deformities of the Oropharynx. Malformation and 
Deformities of the Uvula. Retropharyngeal Abscess. 
Ulcerations and Adhesions of the Uvula and Soft Palate . . 686 

Diseases of the Oropharynx (Continued). Simple Acute 
Inflammations. Acute Infective Inflammations. Traumatic 
Pharyngitis. Toxic Pharyngitis 695 

Diseases of the Oropharynx (Continued). Chronic Hyper- 
plastic Pharyngitis. Chronic Atrophic Pharyngitis. Chronic 
Tonsillitis. Lingual Varix 714 

Diseases of the Pharynx. Neoplasms. Neuroses of the 
Pharynx. Unclassified Affections of the Pharynx 737 



XLVIII. 



XLIX. 



L. 

LI. 

LII. 

LIU. 

LIV. 



Section III. — The Larynx. 

Acute Inflammatory Diseases of the Larynx. Acute Infectious 
Epiglottitis. Simple Acute Laryngitis. Acute Infectious 

Laryngitis. Acute Laryngitis due to Traumatism 746 

Chronic Inflammatory Affections of the Larynx. Chronic 
Hyperplastic Laryngitis. Chronic Atrophic Laryngitis. 
Chronic Perichondritis and Chronic Chondritis. Chronic 
Ankylosis of the Cricoarytenoid Joint. Chronic Arthritis. 
Laryngeal Stenosis. Foreign Bodies in the Larynx. Pro- 
lapse of the Ventricle 7(i3 

Neoplasms of the Larynx 775 

Neuroses of the Larynx 785 

Suspension Laryngoscopy 803 

Direct Laryngoscopy, Tracheoscopy and Bronchoscopy . . 812 
Esophagoscopy 825 

Formulary 829 

Index 834 



LIST OF ILLUSTRATIONS. 



FlG. PAGE 

1 External surface of the adult temporal bone. Landmarks indicated upon key 

plate , Frontispiece 

2 Section of the right temporal bone, the two segments of which show important 

anatomical landmarks. See key plate. (Author's specimen.) Facing 1 

3 Main section of the author's treatment room 2 

4 Author's enameled waste pail with funnel-shaped cover 3 

5 Author's electric headlight with focusing device 4 

6 Compressed air apparatus : 5 

7 Bib for patients 6 

8 Author's cotton box 7 

9 Author's history card 9 

10 Introducing the aural speculum 10 

11 Sharp's modification of Bosworth's nasal speculum 11 

12 Author's modification of Bosworth's speculum with solid flaring blades 11 

13 Myles's nasal speculum 12 

14 Flat wide platinum applicator 12 

. 15 Posterior rhinoscopy 13 

16 White's palate retractor " 14 

17 Michael's postnasal mirror 14 

18 Anatomical conformation of the mouth and pharynx 15 

19 The laryngeal picture — cords widely separated 16 

20 The laryngeal picture— cords in apposition 17 

21 Proper position of surgeon and patient during catheterization of the Eustachian 

tube 18 

22 Catheter properly introduced along the inferior meatal floor 19 

23 Faulty introduction of the Eustachian catheter 20 

24 Catheter tip in position within the Eustachian orifice 21 

25 Eustachian bougie passed through a catheter 22 

26 Siegel pneumatic speculum 22 

27 Fowler's middle-ear inflation apparatus 29 

28 Showing thick membrana basilaris near the lower end of the basal coil 

(Shambaugh) 30 

29 Membrana tectoria about one-half turn from the lower end of the basal coil 

(Shambaugh) 31 

30 Membrana tectoria near the apex of the cochlea (Shambaugh) 32 

31 Politzer's acoumeter 36 

32 Set of Hartman's tuning forks 37 

33 Galton whistle 38 

34 Fowler's resonator apparatus 40 

35 Fracture of the temporal bone through the labyrinth 46 

36 Lateral view of the tympanic cavity and drum membrane, with key plate 63 

37 Marked retraction of the drum membrane 64 

38 Lateral view of the tympanic cavity, drum membrane and bony meatus, with 

key plate 65 

39 Large perforation of the membrana tympani 06 

40 Position of patient for the operation of lumbar puncture (Louis Fischer) 72 

41 Lumbar puncture needle and syringe 73 

42 Anatomical illustration showing the place best adapted for lumbar puncture 

{Louis Fischer) 73 

43 The piston syringe in use 80 

44 The Fowler suction bell douche 81 

45 The suction douche applied to the ear. showing the indrawing of the auricle result- 

ing from the partial vacuum within the glass bell S2 

46 The suction douche apparatus complete, showing the supply bag, rubber 

tubing, etc 83 

17 Li iter ear coil 85 

48 Electric air heater 88 

49 Lucae's pressure sound S9 

50 Points for the subperiosteal injection of cocaine to induce local anesthesia of the 

mastoid process 92 

51 Electric ear speculum 93 

52 Paracentesis bistoury 94 

53 Spear-shaped lancet 94 

64 Incision commonly required Cor opening the drum membrane 95 

55 A lateral view of the inner portion of the external auditory canal and tympanic 

cavity 95 

56 Incision of the drum membrane 96 

.".7 incisions of the membrana tympani 96 

58 Artificial leech. Bacon's scarifier and cupping glass 97 

59 The Bier treatment by constriction band about the neck {Kopeteky) 98 

60 Suction apparatus tor inducing local hyperemia (Fowler) 99 

61 The normal auricle, with landmarks 104 

(ix) 



x LIST OF ILLUSTRATIONS. 

*«»• PAGE 

62 Outer aspect of the right side of the cranium of a fetus at birth, showing entire 

absence of the osseous meatus, mastoid tip, the drum membrane and ossicles 

in situ (Dunning) 105 

63 Eczema of the auricle 109 

64 Facial nerve, geniculate ganglion and relations with the otic (Testut) 114 

65 Herpes oticus. (Partly schematic) 116 

66 Othematoma of the auricle 122 

67 Furuncle of the external meatus viewed through the speculum 125 

6S Lateral view of the external meatus, showing furuncle in posterior wall 127 

69 Syringing the ear for the removal of cerumen 13a 

70 A method to be employed for removing buttons from the external meatus whenever 

the eye or eyelet can be seen by the surgeon 136 

71 Removal of oval object (bean) from the auditory meatus with forceps 137 

72 Quires's foivign-body extractor 13,S 

73 Carious mastoid process. Removed from a child 14 years old (Author's case) 140 

74 Projecting ear, with abnormal droop or lop. There is also redundant cartilage and 

deformity of the helix 142 

75 Diminutive auricle, with absence of external meatus 143 

76 Diagrammatic representation of the normal measurements of the auricle (Goldstein) . 144 
T( The satyr ear 144 

78 Redundancy and deformity of the helix {Goldstein) !.".!.. 145 

79 Bifid lobule. Showing line for incision to be followed in performing a plastic 

operation to overcome the deformity 146 

80 Large horny excrescence projecting from lobule (Author's case) i47 

SI Supernumerary tragus lil , iil ,, ;;: . i:;;;::il i4g 

82 Fistula congenita auris , , , 14S 

n:. M. s5 Usual technique for reducing maerotia (Goldstein) 14S 

86 Usual incisions for correcting deformities of "lop ear" 149 

87, 88, 89, 90 Serve to illustrate the Steps of operation for projecting auricle. (Goldstein) . 150 

91 Postauricular sebaceous cyst (Author's case) i:,i» 

92 Extensive congenital angioma of the auricle, the side 'of the' face' and the "hi ad 

(side view) 153 

93 Same as Figure 92 (front view) 154 

94 Epithelioma of the auricle (Author's case) 157 

95 Same as Figure 94. Later stage of the disease 158 

96 Postauricular osteosarcoma. (Patient of Dr. E. Terry Smith) 160 

97 Exostosis of the external auditory canal. (Partly schematic) 161 

us Rupture of the drum membrane due to concussion from "boxing the ear" 171 

89 Vertical section through left temporal bone in the plane of the axis of the petrous 

portion. (Hindi ■lebcn.) (Colored.) Facing 172 

100 Partly schematic drawing from specimen (enlarged) after Siebenmaiin ' (Koj>el~ki/) " 174 

101 The normal membrana tympani. (Colored.) Facing 174 

102 The landmarks of the membrana tympani 175 

103 Lateral view, showing the normal relations of the external auditory canal drum 

membrane, ossicles and tympanic cavity 176 

104 Showing early stage of serous transudate into the tympanic cavity as a result of 

an attack of acute catarrhal otitis media. (Partly schematic) 182 

105 Congested blood-vessels along the line of the malleus handle. The drum membrane 

is retracted 4g2 

106 Hyperemia of the blood-vessels of the drum membrane' during 'the early' stag'i of 

acute catarrhal otitis media , 1S2 

107 Showing upper level of tympanic transudate. Drum membrane retracted ! 183 

108 Air bubbles in the tympanic transudate, following inflation. (Partly schematic) .. 183 

109 Change in the level of the fluid induced by tipping the patient's 'head backward 

(Partly schematic) jg3 

110 Lateral view of the tympanum, showing air bubbles in the 'transudate.'" (Partly 

schematic) 18 4 

111 Drum membrane retracted '" 139 

1 12 Malleus handle foreshortened 189 

113 Atrophic drum membrane, showing shadow of the long process of the incus, the 

incudostapedial articulation and the round window '. 190 

114 Retraction of the drum membrane with calcareous plaques 190 

115 Large perforation healed over with a thin layer of tissue 190 

116 Lateral view of the tympanic cavity, with key plate. (Partly schematic) '.'.'" 191 

116<(. Holmes nasopharyngoscope 192-3 

116// Pharyngeal opening of the normal Eustachian tube"."'.""!"!!"]"""..'!! 199.3 

116c Anatomically constructed tube (chronic epipharyngitis and salpingitis) 192-3 

116(« Papilloma attached to the posterior superior wall and about one-third inch from 

the orifice of the tube 192-3 

116c Two adenomatous polyps arising within the tube. Both turbinals, much hyper - 
trophied, resting upon the anterior lip of the tube and in contact with the 
growths within the lumen of the tube 192-3 

117 Inflammatory engorgement of the blood-vessels of the membrana tympani..!! 202 

US Bulging of the drum membrane 202 

119 Lateral view of the tympanum, with key plate, partly schematic, showing bulging 

of the drumhead (1), pus in the tympanum (2), and absence of the usual 
prominence of the processus brevis (3) 203 

120 Lateral view of the tympanum, with key plate, partly schematic, showing (1) bulg- 

ing of drumhead. The tympanum is nearly filled with pus (2), the long 
process of the malleus (3) is forced outward with the bulging drum and the 

usual prominence of the short process (4) is partially obliterated 204 

1-1 Lateral view of the tympanum, partly schematic, showing perforation in the lower 

segment of the drum membrane 205 



LIST OF ILLUSTRATIONS. X1 

FIG. PAGE3 

122 Lateral view of the tympanic cavity and drum membrane, partly schematic, show- 

ing extravasation of exudate between the layers of the membrana tympani 206 

123 Marked bulging of the posterosuperior quadrant of the drum membrane 207 

124 External periostitis of the mastoid process due to furunculosis of the external 

auditory meatus and simulating advanced acute mastoiditis 211 

125 Subperiosteal mastoid abscess 211 

126 Lateral view of the external auditory canal and tympanic cavity 21S 

127 Localizing points of tenderness upon pressure over the mastoid process 219 

127a Radiograph of a normal mastoid process (pneumatic type) 220-1 

127b Radiograph of a normal mastoid for the purpose of comparison with its fellow 

(c) the diseased mastoid 220-1 

127c A diseased mastoid process with broken-down cell walls 220-1 

128 Wooden block, grooved for head rest during operation upon mastoid process 

(S. Richardson) 225 

129 The head in position upon grooved block 225 

130 Photograph showing the arrangements completed for performing a mastoid 

operation 226 

131 A complete set of instruments for the mastoid operation, including the emergency 

instruments required for complications 227 

132 Temporal bone, external surface, showing landmarks 228 

133 The primary incision through the soft tissues of the mastoid process 229 

134 Langenbeck's hoe periosteal elevator 229 

135 The Douglas periosteal elevator : 229 

136 Cutting the outer portion of the attachment of the sternomastoid muscle to the 

tip of the mastoid process 230 

137 Allport's mastoid wound retractor 231 

138 Jansen's mastoid wound retractor 231 

139 Jack's mastoid wound retractor 231 

140 Showing the cortex of the mastoid process with the soft tissues retracted by self- 

retaining retractors 232 

141 The posterior mastoid incision 233 

142 Chiseling the antrum cortex 234 

143 The mastoid antrum opened and a curved probe inserted through the aditus 235 

144 Set of mastoid chisels and gouges • 236 

145 Removing the cortex with rongeur forceps 237 

146 Excavating cells and granulations with curct, and the technique of biting the 

overhanging cortex with the rongeur forceps 238 

147 The specimen shows a continuation of the mastoid cells into the basilar process 

of the occipital bone (Dunning) 239 

148 A set of rongeur forceps comprising those in common use 240 

149 A completed simple mastoid operation 241 

150 Exposure of the dura in the region of the antrum and attic tegment, and exposure 

of the lateral sinus 241 

151 Extensive excavation of the mastoid process and the zygomatic cells {Dunning).... 242 

152 Author's portable operating table 243 

153 Author's complete sterilized outfit 244 

154 Portable sterilizer. Alcohol burner 215 

155 The mastoid wound packed with gauze and its upper portion united with sutures.. 246 

156 First step in applying the mastoid bandage 247 

157 The completed mastoid bandage 24S 

158 The double mastoid bandage 249 

159 Postoperative temperature curve, showing continuous flat temperature 250 

Pin Temperature chart, illustrating postoperative elevation of temperature 

161 Temperature chart, showing the usual postoperative rise in temperature on t 

day following the operation < 

162 Large granulations involving the intratympanic mucosa 

163 Showing an aural polypus projecting through a perforation in the drum membrane.. 255 

164 Polypus protruding from a perforation in Shrapnell's membrane 

!i;r,, 166 Lateral view of til'' tympanic cavity, partly schematic] with key plate 260, 261 

167 Perforation in the drum membrane, which has healed over 262 

168 Lateral view of tympanic cavity, with key plate, partly schematic 263 

169 Perforation of drum membrane which does not impinge upon bony structures of 

middle ear 

iTo small perforation at umbo 

ill Perforation of large size in central portion of drumhead 

172 Loss of entire central portion of drum membrane and small portion of membrana 

flaccida 265 

173 Almost entire absence of drumhead proper ami ni< ■mhra na llaceida 265 

171. 175 Multiple perforations in drumhead 266 

176 Large perforation in Shrapnell's membrane, through which the carious malleus 

and Incus are visible 267 

177 Perforation of upper posterior quadrant al junction of drum membrane proper with 

Shrapnell's membrane 267 

I7S An attic cannula in position 269 

179 Si. are passed alone; the polypus, the mass meanwhile being engaged within the 

wire loop .* 270 

180 A hypodermic needle, introduced along upper portion of osseous canal wall to 

Inject local inesthetic 273 

im A schematic drawing representing fleld of Intratympanic operation 274 

182 Circle i, out r extremity of aural speculum, Introduced Into external auditory 

canal. Dotted circle /•'. drumhead to be incised. Inner circle 0, portion of 
drum membram visible to eyi of operator a1 one time 274 

183 Primary incision to sever drumhead Cron il i- >■,,!,, i-,i tttachments 275 



x ii LIST OF ILLUSTRATIONS. 

FIG. PAGE 

184 Tenotomy knife introduced into tympanic cavity at a point above level and behind 

short process of malleus to sever tendon of tensor tympani muscle 275 

185 Position of tenotomy knife after tendon of tensor tympani has been severed 275 

186 Angular extracting forceps introduced into tympanic cavity, firmly grasping malleus 

preparatory to its removal 276 

L87 Position of incus hook when introduced to rotate incus downward and forward 

preparatory to its removal 276 

ins .1. sharp ring curets. B, angular sharp curets 277 

L89 Kerrison chisel forceps in position for removing outer wall of aditus (attic) 278 

190 Jansen's fibrocartilaginous wall retractor 281 

191 A completed tympanomastoid excavation 2S2 

102 The Staeke protector 283 

192a Set of Allport's burrs 282-3 

193 The Richards curet 284 

104 Eustachian curet (Neumann) 284 

195 Anomalous position of the facial nerve, with plate (Dr. T. P. Bereim) 286 

L96 Complete facial paralysis 288 

107 Same patient. Taken while attempting to close the eyes i 280 

108 The Staeke meatal flap 201 

L99 The Panze meatal flap 292 

20ii The dotted line indicates the location of the primary incision to be followed in 

constructing the Staeke, the Panze and other modifications of the Staeke 
skin-flap 293 

201 A posterior view of the primary incision. (Diagrammatic) 294 

202 The final incision in the modified Staeke meatal flap. (Diagrammatic) 205 

203 Meatal skin-flap stitched to temporal fascia above. (Diagrammatic) 296 

204 The Homer meatal skin-flap. (Diagrammatic) 297 

205 Primary incision in construction of the Neumann modification of the Siebenmann 

meatal flap 298 

206 Completing incision for the Neumann modification of the Siebenmann meatal Hap 

with scissors 299 

207 The Neumann modified Hap completed. (Diagrammatic) 300 

208 The Ballance meatal skin-flap 301 

209 A razor, with one flat surface, especially applicable for removing Thiersch's 

skin grafts 301 

210 Mattress suture employed for closure of postauricular mastoid wound 302 

211 A mastoid wound closed by mattress sutures and reinforced by interrupted sutures.. 302 

212 The Michel metal clamp suture outfit 302 

213 The technique of applying the Michel clamp suture to the postauricular mastoid 

wound • 303 

214 The first step in the closure of a postauricular fistula. (Passow-Trautmann 

method) 303 

215 Second stop in the Passow-Trautmann operation for closure of a postauricular 

fistula 304 

216 The first row of sutures have been tied, the knots being still visible 304 

217 Incision shows U-shaped skin-flap cut from inferior margin of postauricular opening. 

(Mosetig-Moorhof method) 305 

218 Second incision, which releases skin around border of postauricular opening. 

i Hosi tig-Moorhof method) 305 

219 The third step. (Mosetig-Moorhof method) 3Q6 

220 The final step in the Mosetig-Moorhof operation 306 

221 Methods of suturing to be followed in end-to-end anastomosis of nerve trunks. 

(Schematic) 308 

222 Schematic illustration of lateral implantation of anastomosis of nerves 309 

22:; Schematic illustration of dissection for anastomosis of facial nerve with hypo- 
glossal nerve 310 

221 Schematic representation of anastomosis of severed end of facial nerve with hypo- 
glossal nerve by lateral implantation " 311 

225 Author's rotator for conducting the rotation tests for nystagmus 316 

226-238 Rotation tests for nystagmus 317-328 

230 Mnemonic diagram of the canalicular system of the right side 329 

240 Dissection of the temporal bone, with key plate ;;:;n 

211 Deep dissection of the temporal bone, with key plate 332 

242 Author's noise producer ;;:;; 

243 Baran y 's noise producer 338 

244, 245, 246, 247, 248 Operation upon the labyrinth. (Richards.) (Colored.). .'.'.'.'."Facing 342 

249 The modiolus 342 

250, 251 Sinus bone specimens '.'/. 346 347 

252 Radiograph showing purulent invasion of a sigmoid sinus . 348 

253a, b, C, d, e Sections from temperature chart of a case of O. M. P. C, complicated 

with sinus-thrombosis with symptoms of typhoid fever 352. 353 354 

2o4 Osseous covering (inner cranial table) of lateral sinus excavated from level of 

jugular bulb upward and backward toward the torcular 359 

255 Resection of the jugular vein 361 

256 Method advised for incising the dura for purpose of drainage.'..'.'.".'.'.".!'.'.!'.'.'.'.!'.!!!'.! 371 
2;>7 Trephine operation upon the temporosphenoidal lobe 372 

258 Circular flap over the squama for purpose of trephining the skull 373 

259 Section of temporal bone in which thinness of inner (cranial) table and region of 

tegmen is depicted (Author's specimen) :;74 

o« £ otoucned Photograph of encapsulated brain abscess. Natural size (II. P. Slnshcr).. 375 
<2bl Brain, showing lesion produced by an abscess in the temporosphenoidal lobe 

(//. P. Mosner) . 376 



LIST OF ILLUSTRATIONS. x [[\ 

PIG. PAGE 

262 Exposure of dura of middle cranial fossa by removal of the attic and antrum 

tegmen 381 

263 A long slender-bladed scalpel for incising the brain substance 381 

264 Spongification of the labyrinthine capsule (Katx) 386 

265 Spongification of the labyrinthine capsule (ISiebenmunn) 3S6 

266 Tubercle bacillus. (Human type) 408 

267 Tubercle bacillus. (Bovine type) 409 

268 Extensive lupus vulgaris of the face, nose, mouth, ears and neck. (From collec- 

tion of Dr. John A. Fordyce) 411 

269 Lupus vulgaris. (From collection of Dr. John A. Fordyce) » 415 

270 Tuberculous ulceration of the gums. (Robert Levy.) (Colored.) Facing 418 

271 Tuberculous ulceration of the hard palate, soft palate, uvula and posterior wall 

of the pharynx. (Robert Levy.) (Colored.) Facing 418 

272 Tuberculous ulceration of the tongue. (Dr. J. C. Sharp.) (Colored.) •.. .Facing 418 

273 Tuberculous ulceration, of the tonsils. (Robert Levy.) (Colored.) Facing 418 

274 Tuberculous infiltration of the epiglottis 423 

275 Tuberculous ulceration of the vocal cords 424 

276 Krause-Heryng laryngeal cutting forceps 427 

277 Killian laryngeal cutting forceps 428 

278 Yankauer laryngeal medicine dropper 429 

279 Leduc's autoinsufflator 430 

280 Primary chancre of the nose. (From collection of Dr. John A. Fordyce) 437 

2'81 Gumma of the tongue healing. (Dr. John A. Fordyce.) (Colored.) Facing 438 

282 Interstitial glossitis. Syphilis 6 years old. (Dr. John A. Fordyce.) (Colored.). .Facing 438 

283 Nasal deformity (saddle-back) resulting from syphilitic necrosis of the nasal and 

turbinate bones 440 

254 Collapse of anterior portion of nose 441 

255 Cicatricial adhesion of the soft palate to the posterior pharyngeal wall 442 

286 Cicatricial web-formation between the vocal cords 443 

257 Diphtheria or Klebs-Loeffler bacilli (Lenharts-Broolts) 450 

258 Common, follicular, hemorrhagic, and septic tvpes of diphtheria. (Fischer.) 

(Colored.) Facing 452 

289 Antitoxin syringe 456 

290 Nasal syringing in contagious cases of Riverside Hospital (Fischer) 457 

291 O'Dwyer's set of intubation instruments 458 

292 Mummy bandage, showing child in proper position for dorsal method of intuba- 

tion (Fischer) 459 

293 Intubation. First step in operation (Fischer) 460 

294 Intubation. The tube passing the epiglottis (Fischer) 461 

295 Casselberry metbod of feeding (Fischer) 462 

296 Extubation. First step in operation (Fischer) 463 

297 Extubation. Second step in operation (Fischer) 464 

298 A tracheotomy tube 465 

299 Lateral view of the tracheotomy tube in position 466 

300 Leprosy. (Photograph loaned by Dr. K. Echeverria, of Costa Rica) 481 

301 The Faught blood-pressure apparatus 4S6 

302 The Faught blood-pressure apparatus applied to a patient's arm 4S7 

302a Radiograph illustrating status lymphat.cus 490-1 

303 The In- Yilbiss hand atomizer 497 

304 Fowler's nasal douche 512 

305 Postnasul syringe 513 

306 The anatomical formation of the nasal septum. (Dearer.) Facing 518 

307 Septal spur parallel with floor of nasal cavity 519 

308 The cone-shaped septal spur situated upon the vomer 519 

309 A deflected septum of normal thickness throughout and without spurs or crests... 520 
31.0 A deflected and thickened septum with a ridge upon each side 520 

311 The vertical deflection of the nasal septum 521 

312 A diagrammatic representation of the sigmoid or S-shaped deflection 522 

313 The Adams forceps for overcoming the resiliency (crushing) of a deflected septum.. 524 

::i 1 Diagram of Gleason's operation 524 

31.". The Itoe septum forceps 525 

316 The vulcanized rubber 'splint 525 

:;17 Asch's straight scissors 526 

31S Asch's angular scissors 526 

319 Asch's septum forceps 527 

820 Mayer's nasal tube splint 527 

321 Schematic representation of the two incisions in the Asch operation 528 

322 Ballenger's mucosa knife r.30 

322a Showing the line of incisi* ployed by Hajek, Killian, and Y/ankauer 533 

3226 Freer's L-shaped incision Cor the submucous resection operation 532 

323 Perichondrium elevators, a, Ballenger's, b, Freer's 533 

324 Small oval curet for penetrating the Beptal cartilage 533 

325 Specimen of Beptal cartilage removed with the swivel knife 533 

326 Mucochondrlum separated fr both sides of cartilage in accordance with descrip- 

tion in text 534 

327 The Ballenger swivel knife 534 

328 Foster-Ballenger's bone-cutting forceps [or removing portions of the vomer 535 

329 ECillian's submucous speculum 535 

330 Submucous hand retractor 585 

83] Allen- 1 I eld ■ruiiiiin's submucous speculum 536 

232 Ynnk.iucr's periosteum elevator 536 

333 Bone-cuting forceps 536 

884 The crotch-chisel applied to the maxillary ridge 537 

3:::. The ii;,|.k septal oblsel 537 



xiv LIST OF ILLUSTRATIONS. 

FIG - PAGE 

336 The Douglas douche bag 53g 

337 Submucous resection set, containing the models devised by Yankauer and others"."!! 539 

338 Removal of the projecting free border of the septal cartilage 540 

339 Septal spur which impinges upon the inferior turbinal 541 

340 The Bosworth nasal saw 541 

341 The Payne nasal saw !!!!!.!!!!!! 542 

342 Simpson's (Berney's) sponge tampon !.!!!!!!!!!!!! 542 

343 Knight's angular scissors . . 543 

344 A perforation of the cartilaginous septum 544 

345 Vertical coronal section of the skull, with key plate .'.'!! .".!!.'!!!! 547 

346 Cystic middle turbinal with a large edematous polypus 549 

347 Angular flat applicator 551 

34S Griinwald's punch forceps !!!!!!!!!! 551 

345 The primary incision for the middle turbinotomy .!...' 552 

350 The Holmes middle turbinal scissors 553 

353 The Krause nasal snare !!!!!!!!!!!! 663 

352 The snare in position for severing the anterior portion of the middle turbinal 554 

353 The partial middle turbinal operation, with key plate 555 

354 A large sessile hyperplasia (polypoid) removed from the posterior extremity of the 

inferior turbinal of an asthmatic ' 557 

355 Bilateral posterior hyperplasia (cauliflower) of the interior turbinals 558 

356 The Jackson turbinotomy scissors 559 

357 The snare in position for removing a posterior hyperplasia of the inferior turbinal.. 560 

358 The Mial turbinal snare : 561 

359 Partial (anterior) inferior turbinotomy by means of punch forceps 561 

360 Partial (anterior) turbinotomy by the combined employment of the punch or scissors 

and the snare 562 

361 The Berens spokeshave 563 

362 Various synechias (adhesions) observed in nasal cavities 564 

363 Front view of a vertical coronal section of the skull on the plane of the second 

molar teeth, with key plate 567 

364 Dissection showing the antral surface of the nasoantral wall and ostium maxillare. 

with key plate 56(1 

365 The outer or temporal wall of the maxillary antrum, with key plate 571 

366 The location of ostium maxillare and exploratory puncture of maxillary antrum 574 

367 Transillumination of the maxillary antra (antra of Highmore). (Colored.) ..Facing 574 

368 The Coakley transillumination lamp 575 

369 Myles's antrum trocar and cannula 576 

369« Coflin's suction pump apparatus 578 

370 Myles's antrum irrigation tube 579 

371 Myles's reverse antrum chisel punch '.!!'.!!! 579 

372 Radical operation for chronic empyema of antrum (Harmon Smith) 580 

372a Gouge devised by Curtis for opening nasoantral wall 5S1 

373 Wagener's forward-cutting antrum forceps .!!!!!!!!! 581 

374 Ostrum's forward-cutting forceps ! . 582 

375 Myles's malleable shank antrum curets 5,s!i 

376 First step in the! Jansen antrum op ration 5S4 

377 Second step (resection of bone) in the Jansen antrum operation 585 

378 Orifices of the nasal accessory sinuses. (Deaver.) I' :: 

378« The abnormally large right frontal s:nus. (Dunning.) Facing 586 

37S6 Same specimen viewed with head tilted slightly backward. (Dunning.) Facing 586 

379 Heath's frontal sinus probe » 591 

380 Killian's frontal sinus cannula 591 

381 Intranasal drainage of the frontal sinus (Ingals) !!!!!!!!!! 592 

382 Transillumination of the right frontal sinus. (Colored.) Facing 592 

383 Two photographs of a model constructed to show the effects of changing the posi- 

tion of the tube with reference to the skull (CahhccU) 593 

384-390 Skiagraphs of frontal sinuse s Facing 594 

3X4 Skiagraph shows cloudy appearance in right frontal sinus, ethmoidal cells and ' 

maxillary antrum, indicating empyema of these cavities Facing 594 

3S5 Skiagraph shows the nearly symmetrica! frontal sinuses containing numerous 

septa ■ Facing 5! 4 

386 Skiagraph shows a very large right and small left frontal sinus, both containing 
septa Facing 594 

357 Skiagraph shows lateral projection and depth of the frontal sinus s Facing 594 

358 Skiagraph shows small symmetrical frontal sinuses Facing 594 

389 Skiagraph shows total absence cf the frontal sinus Facing 594 

390 Skiagraph shows slightly asymmetrical sinuses Facing 594 

391 Halle's frontal sinus burrs and handle ....597 

392 Ingals's pilot burr !! ! 59s 

393 Ingals's frontal sinus drainage tube ! . ! 599 

394 Killian's packing forceps 509 

395 Killian's operation. First step (Harmon Smith) ' , .' 6(111 

396 Killian's operation. Second step (Harmon Smith) 601 

397 The Killian protector " " 60" 

398 Killian's V-shaped chisel 602 

399 Killian's operation. Third step. (Harmon Smith.) Facing 602 

400 Killian's operation. Lateral appearauce after dividing the head (Harmon Smith) 6^3 

401 Briining's forceps Q04 

4(i2 Griinwald's sphenoidal forceps ..604 

403 A complete set of instruments for operating upon the nasal accessory sinuses 605 

404 Cosmetic results of a Killian frontal sinus and antrum operation upon the left 

side (Author's case) 606 



LIST OF ILLUSTRATIONS. xv 

PIG. PAGJ3 

405 Cosmetic results of a Killian frontal sinus operation upon, the left side (Author's 

case) 607 

406 Left and right sphenoids, chiasm, posterior ethmoid cells, frontal sinuses, internal 

cartoid ' (Loeb) 610 

407 Left labyrinth, sphenoids, posterior ethmoid cells, optic nerve, trifacial nerve 

(Loeb) 617 

408 Front view of a slightly slanting coronal section of the skull, with key plate 622 

409 Probe in sphenoidal sinus 624 

410 Myles's sphenoidal cannula , 626 

411 Sphenoidal punch forceps 627 

412 A twisted nose 629 

413 Dislocation of both nasal bones and transverse deflection of the cartilaginous septum 

caused by external violence '. 630 

414 Smith's paraffin syringe 632 

415 The paraffin cup 633 

416 Photograph of a saddle-back nose, the result of external violence 634 

417 The saddle-back deformity, shown in Fig. 416, corrected by an injection of paraffin.. 635 

418 Bridge and intranasal splint for correcting depressed deformities of the nose 

(Carter) , 636 

419 Sectional view of splint and bridge in place (Carter) 636 

420 Mechanics of the intranasal splint and bridge (Carter) 637 

421 Primary incision for dissecting a flap from the floor aud septal side of the meatus 

(Maekenty) 637 

422 Backward dissection across along the floor at the mucocutaneous junction 

(Maekenty) 638 

423 Flap dissected from the floor of the nostril (Maekenty) 639 

424 Flap sutured to the line of the original incision ((Maekenty) 639 

425 A false nose 640 

426 The Belocq sound 641 

427 Benefit to be gained by traction rather than by severing the polypoid mass 654 

428 Large mucous polypus, exact size 655 

429 Ollier's incision to obtain a wide opening of the nasal cavities 659 

430 The choanaa 662 

431 Lateral view of the anatomical conformation of the nose, nasopharnyx, pharnyx, 

and larynx (Denver) 663 

432 The author's flexible cotton carrier 665 

433 Sessile masses of adenoids in the vault of the pharynx 667 

434 Group of public school boys who had adenoids and hypertrophied tonsils 669 

435 Same boys as Nos. 1, 2, 3, of Fig. 434, after operation 670 

436 The typical adenoid facial expression - ._. 671 

437 Same boy as in Fig. 436, after the removal of adenoids 671 

438 Group of "mentally defective children with adenoids" 672 

439 Denhart's mouth-gag 674 

440 The Chapin tongue depressor 674 

441 The Brandegee adenoid forceps 675 

442 The Beckman adenoid curet 675 

443 The Stubbs adenoid curet 676 

4-14 The Coffin small curved adenoid ring curet 676 

445 Position of patient, operator, and assistants for removal of adenoids and tonsils 

under general anesthesia 677 

446 The Thompson protector for the adenoid curet 67S 

447 Schematic representation of the removal of adenoids by means of the curet 67S 

448 Large adenoid, actual size, showing linear folds and deep depressions 679 

449 The Hunter sponge holder 680 

450 Adhesive bands from adenoid mass in connection with Eustachian tubes 6S1 

451 The Author's galvanocautery knife for dividing adhesions in the nasopharynx .... 682 

452 The Hooper adenoid forceps 6S5 

453 Bifid uvula 6S9 

454 The McKenzie uvulotome 690 

455 Edema of the uvula, with small punctures for the removal of serum 691 

450 Carmine granules passing the epithelium of the tonsil from without, bacteria re- 
maining on the surface. (Jonathan Wright.) (Colored.) Facing 700 

457 The exudate of Vincent's angina upon the tonsil (Arrowsmith) 705 

458 Suitable history for incising peritonsillar abscesses 70S 

459 The general appearance of a peritonsillar abscess, and the line of incision for its 

evacuation 709 

460 Extensive involvement of the pharyngeal walls with Vincent's angina ( Irrowsmith) . 710 

461 Exudate of Vincent's angina extending over the tonsil, velum, and a portion of the 

buccal cavities ( Irrowsmith) 711 

462 Glandular enlargement and dilated veins which accompany chronic granular 

pharyngitis 717 

463 Mayer's pharyngeal curet 71S 

464 Points for injecting cocaine to induce local anesthesia of the .tonsil 723 

465 Thomson's tongue depressor 723 

466 Tho Author's tongue depressor devised for the tonsil operation 721 

467 Thomson's tenaculum tonsil forceps 721 

168 Carter's tonsil tenacluum .' 725 

469 Leland's tonsil separator 725 

470 Douglas's tonsil knife 726 

471 Kyle's tonsil crypt knife 726 

471'/ and I7i'< Wagner's adaptation of the Michel clamp suture for the control of tonsil- 
lar hemorrhage 727 



xvi LIST OF ILLUSTRATIONS. 

fig. PAGE 

472 Primary incision for separating the hypertrophied tonsil from its attachments 727 

473 The Hurd tonsil separator 72J 

474 The Moseley tonsil snare • ■ J-J* 

475 The tonsil snare applied to the loosened and evulsed tonsil rJi 

476 Tonsils removed by dissection and snare 730 

177 The Myles tonsil punch p> 

477,/ Sluder's method for the removal of the faucial tonsils e.,0-1 

478 Rosenheim's tonsil ligature-carrying hemostat 731 

479 Hurd's tonsil hemostat •"" '31 

480 The Miculicz-Stoerck tonsil hemostat ■ J.32 

481 Cavity from which tonsil has been removed ^3„ 

ls2 The Robertson tonsil scissors 734 

483 McKenzie's tonsillotomy 734 

4S4 The Mathieu tonsillotome <35 

485 The lingual tonsil and lingual varix [35 

186 The Myles lingual tonsillotome '36 

487 Large angioma of the uvula removed by the galvanocautery snare 739 

iv-. I iiilatcrai paralysis of the velum palati 743 

489 Superior aperture of the larynx i Dearer) 74 1 

490 Anterior external structures of the larynx [Dearer) 749 

491 Posterior external structures of the larynx [Dearer) 750 

492 View of the internal lateral structures of the larynx (Dearer) 751 

493 The intratracheal cannula and syringe 752 

494 The Hays pharyngoscope and laryngoscope i//<m/m 755 

495 The Tobold concealed laryngeal scarifier 756 

49G Edema of the epiglottis and arytenoids relieved by incisions 751 

497 Croup kettle or steam inhaler 761 

498 Inflamed and thickened vocal cords 760 

499 Singer's nodules upon the vocal cords 709 

500 Various laryngeal forceps from the models of Frankel, Scheinmann, Krause, etc. .. 770 

501 Dundas Grant's laryngeal forceps 771 

502 Laryngeal forceps in position for severing a papilloma from the vocal cord 777 

503 Tuberculous ulci ration of the larynx 780 

504 Position of the vocal cords during forced inspiration 788 

505 Position of the vocal cords during ordinary inspiration 7SS 

506 Diagrammatic representation cf the centers of respiration and phonation in the 

brain and medulla oblongata and their tracts (Rethi) 7S9 

507 Bilateral abductor paralysis during inspiration 791 

50S Bilateral abductor paralysis during expiration 791 

509 Paralysis of the left abductor as seen during forced inspiration 791 

510 Paralysis of the right recurrent laryngeal nerve during inspiration 793 

511, 512 Paralysis of the right recurrent laryngeal nerve during phonation 793 

513 Cadaveric position of cords in bilateral paralysis of recurrent laryngeal nerve 794 

514 Bilateral paralysis of recurrent laryngeal nerve during extreme effort to phonate . . 791 

515 Hi hit oral adductor paralysis of the larynx 794 

516 Paralysis of the artenoideus muscle 796 

517 Bilateral paralysis of the internal tensors during respiration 796 

518 Bilateral paralysis of the internal tensors during phonation 796 

519 Bilateral paralysis of the external tensors (cricothyroids) 797 

520 Complete bilateral paralysis of the supralaryngeal nerve 797 

521 Lyneh's suspension apparatus 803 

522 1 >ental spoons and tooth-plates 804 

523 Table at full height with shoulder and foot braces 805 

524 Introduction of bronchoscope under direct view 806 

525 Demonstrating hook, tilted to patient's right S07 

526 Hook tilted to left 808 

527 Elevation of ring, out of way of bronchoscope 809 

528 Removal of spatula 810 

529 Interior of larynx, showing vocal cords in direct view 811 

530 The Killian straight tube spatula 813 

531 The Killian split tube spatula 813 

532 The Killian bronchoscopes 814 

533 Kirstein's headlight 814 

534 Jackson's bronchoscopy tubes 815 

535 Jackson's tubular speculum 816 

536 Jackson's separable speculum for passing bronchoscopes 817 

537 Jackson's secretion aspirator 817 

538 Jackson's foreign body forceps and other instruments for removal of foreign bo 

539 Mosher's foreign body forceps 818 

540 Mosher's safety-pin closer 819 

511 Coolidge's sponge holder. (Modified by Jackson.) 819 

542 Jackson's improved double-cell battery, arranged for furnishing current to the small 

lamps which are employed in bronchoscopy 820 

543 Sajous's cotton-holding forceps for preliminary cocainization 820 

544 Direct laryngoscopy, patient sitting (Jackson) ." 821 

545 Left upper tracheobronchoscopy, patient sitting (Jackson) 821 

516 Left upper tracheobronchoscopy, dorsal position (Jackson) 822 

517 Tracheobronchial tree (Jarkxon) 822 

548 Skiagraph of a safety pin imbedded in the larynx. (Author's collection.) 823 

549 Diagrammatic position of the left hand in starting the esophagoscope or gastro- 

scope (Jackson ) 826 

550 Position of second assistant and patient for endoscopy per os (Jackson) 827 










O 
£ . 

■+-> qj 



PART I. 

The Ear. 

SECTION I. 

General Considerations. 



CHAPTER I. 
THE OFFICE EQUIPMENT. 

To facilitate the examination and the treatment of patients 
suffering- from diseases of the. ear, nose and throat, in harmony 
with our more modern ideas, a special office equipment is essential. 
In devising the necessary office paraphernalia the chief considera- 
tions are efficiency, simplicity, convenience and cleanliness. 

Various general forms of office equipment are in vogue, depend- 
ing largely upon the individual peculiarities of the surgeon. For 
the actual treatment of patients most operators employ a corner of 
the general consulting room ; others set apart a special small room 
known as the "treatment" room. The author prefers the latter 
arrangement, inasmuch as within a space comparatively small, when 
this is well utilized, it becomes possible to concentrate all necessary 
working utensils in a space which can be kept clean. 

For those who do not employ office nurses, the treatment room 
affords additional facilities. 

The author's treatment room, one end of which is shown in 
Fig. 3, measures 5x7 feet, and has a side entrance. The floor may 
be of cement or tile, and the walls of tile at least to the height of 
five or six feet. For the upper portion of the walls and the ceiling, 
enamel paint is sufficient. A room of this kind, when equipped 
with enameled furniture, and scrubbed every morning before the 
work of the day begins, does not easily become contaminated, hence 
it is safe for both physician and patient. 

It is furthermore possible in such a room to dispense entirely 
with wooden furnishings, inasmuch as all forms of office para- 
phernalia are now manufactured in enameled metal, and the danger 
of infection connected with the more absorbable wood and leather- 
covered furniture is eliminated. Such a room may be darkened, 
and thus become valuable for applying the transillumination tests. 

The treatment room should contain the following articles of 
enameled furniture: — 

A revolving chair (Fig. 3) with stationary attachment to the 
wall, if possible, in order to economize floor space; otherwise it may 

(1) 



GENERAL CONSIDERATIONS. 




Fig. 3. — Main section of the author's treatment room. 1, Push buttons 
in jamb of treatment room door. 2, Vibratory massage applicator. 3, 
Wall electric switchboard. 4, Electric light. 5, Electric motor for galvano- 
cautery, pump massage and vibratory massage. 6, Enameled receptacle 
for soiled instruments. 7, Drawer for absorbent cotton. 8, Enameled 
waste pail. 9, Revolving arm chair with head rest for the patient. 10, 
Revolving stool for the surgeon. 11, Treatment room cabinet with glass 
top and drawers. 12, Running water cuspidor. 13, Electric sterilizer. 
14, Stack of cheese cloth wipes. 15, Soft silver catheters. 16, Tongue 
depressors. 17, Sterilized ear tips for otoscope. 18, Hartman's ear probe. 
19, Head mirror. 20, Flat-tipped angular applicator. 21, Flexible post- 
nasal and laryngeal applicator. 22, Sharp ring curet. 23, Medicine 
bottles and holder. 24, Sterilized glass spray tip covers. 25, De Vilbis 
atomizers. 



rest upon the floor. The preference for the stationary base of 
attachment is founded upon the patient's tendency to move a chair 
before seating himself, thus disarranging the relative position of 
the light to the chair. 



THE OFFICE EQUIPMENT. 



The advantages of a chair which revolves are, first, that its 
height may be changed to conform to the height of the patient, and, 
second, that the patient may be easily and quickly turned from side 
to side for otologic examinations. 

For the physician a simple revolving stool (Fig. 3) is to be 
preferred, inasmuch as the revolving motion adds materially to the 
ease and deftness of his motions. The author claims priority in the 
use of the revolving seats for both patient and physician. 

Cabinet. — Along the side of the room at the operator's right 
there is a cabinet (Fig. 3) equipped with drawers of various sizes 
and covered with glass upon which instruments, bottles containing 
the various solutions for routine treatment, and if necessary a 
sterilizer may be placed. 

It is necessary to have the top of the cabinet about 31 inches 
from the floor, its width 14 inches and 
length about 40 inches. 

Fountain Cuspidor. — At some point 
convenient for the use of the patient a run- 
ning water cuspidor of glass (Fig. 3) 
should be located and thus all secretions 
immediately removed from sight. 

The waste pail (Figs. 3 and 4) is 19 
inches high and 6 inches in diameter, with 
a funnel-shaped cover into the large open- 
ing of which cotton swabs, soiled gauze 
napkins and other refuse are thrown and 
thereby removed from sight. This pail is 
emptied at intervals and scalded with boil- 
ing water. 

It is desirable and convenient either in 
the larger treatment rooms or in a small 
adjoining toilet room to have a wash basin 
with hot and cold running water, and sup- 
plied with stiff handbrushes and green soap 
to be utilized for scrubbing of hands and cleaning of instruments. 

Personal cleanliness in its minutest details is an absolute essen- 
tial in all work upon the ear, the nose and the throat. 

It is a wise procedure to lay all sterilized instruments upon the 
operator's right side and after use upon a patient to deposit them 
upon a shelf or receptacle (Fig. 3) located at the left side to be 
resterilized. In this manner the danger of mixing soiled instru- 
ments with those that are clean is avoided. 

Sterilizers. — A medium-sized sterilizer operated by gas for 
boiling instruments is reliable, therefore commendable. When an 
office nurse is employed the main sterilizer may be located in an 
adjoining room in order to dispense with the considerable heat 
which it generates. 

A small electric sterilizer (Fig. 3) located upon the surgeon's 
cabinet is useful for dipping spray tips, examining mirrors and 
washing the tongue depressors, nasal specula or other instruments 




Fig. 4. — Author's enameled 
waste pail with funnel- 
shaped cover. 



4 GENERAL CONSIDERATIONS. 

during the treatment of an individual patient. It should in no wise 
supersede the larger sterilizer. 

Illumination. — The examination is conducted by the aid of 
reflected light controlled by the ordinary head mirror (Fig. 3) or 
directly by the means of an electric lamp attached to the surgeon's 
forehead, the former being more convenient and reliable for routine 
office practice. For reflected light, the source may be a kerosene 
or gas apparatus equipped with an Argand burner and a condensing 
lens, or an electric light (Fig. 3) of at least 32 candle power, the 
globe of which should be of ground glass with the exception of an 
oval space in direct line with the surgeon's head mirror. The light 
should be fixed on a movable bracket, so that it may be changed 
to any position demanded by the height of the patient and the 
focal distance of the head mirror used by the operator. 




Fig. 5.— Author's electric headlight with focusing device. The light 
is arranged for use with portable storage batteries or with the street cur- 
rent, the latter requiring the interposition of ~ 
focus is adjusted by rotating the metal cylinder. 



i Ul Willi LUC SllCCl LU1- 

suitable rheostat. The 



The author's headlight with focusing device (Fig. 5) may be 
used with portable storage batteries or attached to the street cur- 
rent by the interposition of a suitable rheostat. For minor opera- 
tions at the patient's house and for major operations upon the ear, 
the nose and the throat, this form of illumination is invaluable. 

Sprays. — Sprays and douches are useful adjuncts to the office 
equipment and are to be utilized for the proper cleansing of the 
nasal passages, the accessory sinuses, the ear and the fauces, and 
for the application of remedial agents to the mucosa and to wounded 
surfaces. 

In the light of our modern knowledge of the etiology of the 
inflammations of the mucosa of the upper air passages, spray 
medication holds a minor position as a curative measure ; neverthe- 
less it has its value. 

The metal spray apparatus of De Vilbiss (Fig. 3) or hard- 
rubber spray outfits of other manufacture are recommended. The 



THE OFFICE EQUIPMENT. 5 

tips of these sprays may be sterilized by boiling or the perforated 
glass spray tip cover devised by Dr. J. J. Thomson may be slipped 
over the spray while in use (Fig. 3). 

Spray solutions are of the following general varieties, viz., 
cleansing, local anesthesia, hemostatic, medicinal and protective or 
emollient. 

For cleansing purposes the physiological normal salt solution 
or alkalol and sterile water in equal parts are recommended. They 
are non-irritating to the mucosa, therefore there is no subsequent 
prolonged watery discharge like that observed following the 




Fig. 6. — Compressed air apparatus. A, Electric air pump. B, Auto- 
matic cut-off. C, Galvanized iron air tank. D, Piping so arranged that the 
air used in tank is drawn from out-of-doors. E, Outlet to office apparatus. 



employment of sprays containing glycerin or remedies which pro- 
duce local irritation. 

Whenever local anesthesia and ischemia are desired, a solution 
containing cocaine 2 per cent, and adrenalin chlorid 1 : 5000, or one 
of alypin 2 per cent, and adrenalin chlorid 1 : 5000. may be care- 
fully sprayed over the mucous surface, the proportions to be 
varied according to the requirements. 

Of the numerous oil spray solutions two are recommended, 
first, Dr. O. P.. Douglas's formula of benzoinol (see Chapter XXXIII) ; 
second, a solution of camphor, 2 per cent., menthol, 2 per cent., in 
benzoinol. The latter is most efficacious as a remedy for intra- 
tracheal injections. 

Compressed-air Apparatus (Fig. 6). — This apparatus consists 
essentially of an electric or a water-compression pump, and some 
form of tank into which the air is compressed. When much in use 
a large tank is to be preferred, if desired a smaller auxiliary tank 
with gauge mav be connected with the main reservoir. "When the 



6 GENERAL CONSIDERATIONS. 

apparatus is located in the cellar the air should be drawn from with- 
out, through piping. 

Instruments. — The routine examination of ear, nose and throat 
patients requires a liberal armamentarium of instruments with a 
sufficient number of duplicates to eliminate the delays incident to 
sterilizing. For convenience it is desirable to have at least a dozen 
complete sets of those most commonly employed. If fewer are 
provided it becomes necessary to continuously resterilize during 
the progress of the day's work. Briefly enumerated the instruments 
for examination include a cluster of aural specula, two or three 
types of nasal specula, tongue depressors, nasal and laryngeal 
applicators, cotton carriers, thumb or angular forceps, laryngeal 




Fig. 7._Bib for patients. Large cotton protector arranged with a fold 
which contains a curved wire spring to fit about the patient's neck. 



and postnasal mirrors, small ring curets, Eustachian catheters 
(Fig. 3), a piston and fountain syringe, a Fowler suction douche 
(Figs. 46 and 47), pus basins, Dench inflation apparatus (Fig. 21), 
Politzer bag, auscultation tube (Fig. 21), Seigel pneumatic specu- 
lum (Fig. 26), Eustachian bougies (Fig. 25), tuning forks (Fig. 
32), acoumeter (Fig. 31), and Galton's whistle (Fig. 33). 

A wall cabinet (Fig. 3) equipped with an electric switchboard, 
current transformers, controllers, etc., supplying currents suitable 
for transillumination, electric bougie, galvanic and faradic pur- 
poses, etc., is indispensable. 

An electric motor (Fig. 3) is useful when equipped with an 
aural massage pump, a vibrator, a galvanocautery attachment, a 
drill and a superheated air device. The fact that this motor may 
be put to so many uses, while it occupies comparatively small space, 
renders it a most valuable addition to the office armamentarium. 



THE OFFICE EQUIPMENT. 7 

A stack of small gauze or cheesecloth wipes (Fig. 3) folded 
into a convenient size are well adapted as a substitute for hand- 
kerchiefs which are not sterile. The expense involved is small and 
is well repaid by the endorsement and approval of the patient. 

To piotect the patient's clothing a bib constructed from a large 
square of cotton (Fig. 7) hollowed along one edge and folded so as 
to contain a curved wire-holding device is worthy of notice. 

A proper-constructed cotton holder is both a time- and labor- 
saving device. The author's cotton box (Fig. 8) or his wire- 
covered drawer (Fig. 3), which is preferable, holds the cotton in 
such a manner that a small or large piece may be conveniently 
removed with one hand, whereas small, loose, absorbent cotton 
requires handling with both hands and several additional manoeuvres 
in order to detach the required segment. 




Fig. 8. — Author's cotton box. The cylinder is detachable from the 
base, the latter containing a strong spring which forces the mass of ab- 
sorbent cotton upward into the wire network at the top. 

Sterilization and Care of Instruments. — All metal and glass 
instruments are made sterile by boiling fifteen to twenty minutes 
in a solution of sodium bicarbonate, about one dram to a pint. 
Before sterilizing they should be washed in running water in order 
that all portions of tissue or blood may be removed. Some rubber 
implements, bougies, etc., which might be injured by boiling, are 
sterilized by immersion for a considerable time in a 1 : 20 solution 
of carbolic acid or a 1 : 4000 solution of bichlorid of mercury. 

Knives may be sterilized by immersing in a tray containing 
alcohol. 

Knives that have become infected by use in pus cases should 
be sterilized by boiling, notwithstanding the probable deterioration 
in the temper of the steel. 



CHAPTER II. 

THE EXAMINATION OF PATIENTS. 

History of the Patient.— The permanent history record should 
be one to which reference can be made at any time with but little 
difficulty. A card index system carefully maintained is preferable, 
inasmuch as a 5 x 8 inch history card is convenient and can easily 
be taken into the treatment room for reference or for recording- 
progress. It should contain a full statement of all essential facts 
relating to the patient's general condition, date and character of 
illness and a full outline of the attack for which he seeks relief. 
The history cards should be filed in numerical order, and cross 
indexed alphabetically by means of small index cards. 

In order to obtain these facts in a concise and comprehensive 
form it is advisable that a set routine be followed in each'case. This 
is best accomplished by having a printed history card such as is 
shown m Fig. 9, which the author has used with satisfaction for 
many years. Having obtained the name, address, age and occupa- 
tion of the patient, we pass to his general history, which often 
proves of considerable value in relation to the specific ailment. 

The Ear.— First inquire about the family history, including 
hereditary deafness, syphilis, tuberculosis and "congenital deafness. 
The personal history should include a note relating to the diseases 
of childhood, such as measles, diphtheria, scarlet fever and any 
attacks of otitic disease. Next we ascertain the history of the 
present attack, its nature, mode of onset and whether or not the 
ear is primarily involved. Duration is especially important in 
chronic purulent infection; likewise the persistency," color and odor 
of the discharge. Other symptoms to be noted are pain, deafness, 
tinnitus and vertigo. These may be noted upon the record card by 
a check sign. If the trouble is non-suppurative in nature or involves 
the inner ear, we go more fully into the character of the tinnitus or 
vertigo; whether or not there is paracusis, and ascertain the 
patient's habits with regard to alcohol and drugs. 

Nose, Throat and Larynx.— What has been said of the Gen- 
eral history relating to the ear pertains, in like manner, to the nose 
throat and larynx. With regard to the special symptoms, inquiry 
should be made whether or not there is obstructed nasal breathing 
through one or both nostrils, whether there is pain referable to the 
regions of the accessory sinuses, and the character and quality of 
the nasal discharge, its persistence, color, odor, consistency and the 
time of the day when it is most profuse. If the history points to an 
artection of the larynx or throat, the symptoms should be noted, 
e.g., cough, hoarseness, aphonia, dysphagia and dvspnea. 

Physical Examination.— Having learned as "much as possible 
from the statements of the patient, we next come to the physical 
examination. 

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10 



GENERAL CONSIDERATIONS. 



Ear. — This includes thorough inspection of the pinna (Fig-. 
61), noting its general formation, its color, its sensitiveness to 
touch, and the presence or absence of swelling or cutaneous affec- 
tions. In examining the external auditory canal and fundus of the 
ear, the relative positions of the patient and examiner are of impor- 
tance. If reflected light is used, the source of light should beat least 
six inches farther back than the patient's head and upon the same 
level as his ear. The patient's gaze should be directly at right 
angles to that of the operator, which brings his ear broadside to his 
view. The introduction of the speculum requires considerable prac- 
tice before the proper degree of skill is acquired. The upper portion 




Fig. 10. — Introducing the aural speculum. Showing method of grasp- 
ing the patient's ear, how to hold the speculum in situ and the angle of 
the patient's head. 



of the pinna should be grasped between the second and third fingers 
and the ear drawn backward and upward, a procedure which 
tends to straighten the canal and to permit a better view of the 
fundus, while the speculum is held between the index finger and 
thumb of the left hand (Fig. 10). The right hand thus remains free 
for adjusting the head mirror and for the instrumentation incident 
to the examination and the treatment. The introduction of the 
speculum never evokes pain unless it is clumsily handled, or when 
there is some disease of the canal walls. Upon its introduction the 
canal should be searched for evidences of inflammation, swelling, 
cutaneous disease, impacted cerumen, exostoses or foreign bodies. 
The fundus is next observed. It is rarely possible to obtain a com- 
plete view of the entire drum at one time except by moving the 



THE EXAMINATION OF PATIENTS. 1 1 

speculum in different directions in order to inspect all the segments, 
and it is essential that the view be obtained by directing the eye 
directly through the central opening in the head mirror. Note upon 
the history chart, and if possible make a rough drawing of the 
appearance of the drum and ossicles; record the relative position 
and color of the surrounding structures, whether or not there is 
secretion, the size, location and general appearance of perforations, 
and the size and location of polypi and granulations when observed. 




Fig. 11. — Sharp's modification of Bosworth's nasal speculum. 

In acute purulent otitis media a smear or culture from the pus may 
be prepared for bacteriological examination. 

It is possible to observe the condition of the lining membrane 
of the tympanum, and also to use a probe for the purpose of detect- 
ing uncovered bone through large perforations. 

In purulent cases the mastoid process should be inspected for 
swelling, redness and tenderness to pressure. If the mastoid symp- 




Fig. 12. — Author's modification of Bosworth's speculum with 
solid flaring blades. 

toms are positive, the temperature and pulse rate must be ascer- 
tained. 

Nose, Throat and Larynx. — The first step in the inspection 
of the nose is anterior rhinoscopy, by which is meant the inspection 
of the anterior portion of the nasal chambers, by means of reflected 
light. For the purpose of distending the nasal orifices numerous 
specula have been devised. TIabit lias much to do with each indi- 
vidual surgeon as to his favorite tvpe. The author varies the form 
of speculum to meet the requirements of the nose to be inspected 
or upon which he intends to operate. 

The steel-wire speculum of Bosworth (Fig. 3), made in differ- 



12 



GENERAL CONSIDERATIONS. 



ent sizes, is an admirable one for examining both adults and 
children. 

When the vestibule is hairy, it may be necessary to employ a 
speculum with solid blades. Sharp's modification of Bosworth's 
(Fig. 11) fulfills the requirement. For operations the author makes 
use of his large-size modification of Bosworth's nasal speculum 
(Fig. 12), which flares at the end of the blade, or the one devised by 
Myles (Fig. 13). 




Fig. 13. — Myles's nasal speculum. 

While making the examination a note should be made of the 
size of the nasal apertures and the character and location of the 
secretions. If pus is found, its origin should be sought. 

A deeper view will determine the size of the turbinals and the 
color of the membrane covering them, the presence of septal deflec- 
tions, spurs, ridges, lesions of the septum or perforations. Hie 
view may be interfered with by the presence of mucus or scabs, 
which may be blown or wiped away. Swellings, polypi or new 
growths should now be observed. At this point the fuller examina- 




Fig. 14. — Flat wide platinum applicator. 



tion is facilitated by holding aside any soft tissue with a flat 
platinum applicator (Fig. 14), or it may become advisable to make 
an application of a weak solution of adrenalin chloride in order 
that the behavior of the tissue under its action may be observed. 
It may be necessary to make an effort to pass a probe into the 
opening of the maxillary, sphenoid or frontal sinus, a procedure 
which cannot always be accomplished until after the removal of 
the major portion of the middle turbinate bone. 

Posterior Rhinoscopy. — By this is meant the inspection of the 
posterior portion of the nasal cavities and of the epi- or rhino- 



THE EXAMINATION OF PATIENTS. 



13 



pharynx. This is accomplished by reflecting" the light on to a small 
mirror passed through the mouth, beyond the soft palate (Fig. 15). 
The tongue of the patient is depressed by a tongue depressor held 
in the surgeon's left hand, while the mirror is manipulated by his 
right hand, the patient being instructed to relax the soft palate by 
attempting to breathe through the nose. Considerable practice is 
often necessary before a patient is able to submit to posterior 
rhinoscopy without gagging. In examining nervous patients or 
those with unusually sensitive throats, it may become necessary to 
anesthetize the pharynx and soft palate with a 4 per cent, cocaine 
solution, or draw the soft palate forward by means of a palate 




Fig. 15. — Posterior rhinoscopy. 



retractor (Fig. 16). Small laryngeal mirrors or Michael's post- 
nasal mirror (Fig. 17) should be employed. 

The office armamentarium should contain tongue depressors 
of various shapes. The Chapin tongue depressor (Fig. 3) is light, 
convenient and answers many needs. Glass and wood depressors, 
the former boilable and the latter to be destroyed after use upon 
one patient, have their advocates. To properly depress the tongue 
the mouth should be fully opened, the tongue to lie in its natural 
position (not protruded) and the depressor when laid firmly upon 
the dorsum in the median line forces it downward between the 
rami of the inferior maxillary bone. A good rhinoscopic view of 
the nasopharynx and postnasal chambers reveals the size of the 
posterior ends of the turbinals, projecting polypi, or discharges 
when present and the presence of adenoids or new growths in the 
nasopharynx. 



14 



GENERAL CONSIDERATIONS. 



Fauces and Pharynx. — In examining the oropharynx (Fig. 
18), the surgeon should take a bird's-eye view of the gross appear- 
ance of the entire area, then observe the condition of the various 
parts, meanwhile recording abnormalities and diseases when found. 

To fully inspect the tonsils it is often necessary to employ a 
ring curette to search the crypts, or a tenaculum to pull the tonsil 
well out between the pillars. Any visible tonsil is pathologic, 
but in some the hypertrophy is extensive and the crypts contain 
cheesy ephithelial detritus. 

The color and thickness of the pharyngeal membrane are 




White's palate retractor. 



matters of importance. Hypertrophied glands upon the postpharyn- 
geal wall (Fig. 462) commonly indicate general lymphatic enlarge- 
ment of tonsils and adenoids, while atrophic conditions indicate 
chronic inflammation of the nasopharyngeal mucosa. 

The Larynx. — In examining the larynx either direct or indirect 
laryngoscopy may be employed. By direct laryngoscopy is meant 
the observation of the larynx through a straight tube inserted 
beyond the epiglottis, obtaining the illumination either by means 
of a small electric light situated at the distal end of the spatula 




Michael's postnasal mirror. 



after the manner of Jackson's invention (Fig. 526), or by the Killian 
method, the light being reflected through the tube by means of a 
Kirstein headlight. By both of these means a direct view not only 
of the larynx is obtainable, but also of a large portion of the 
trachea. 

The indirect method of examination of the larynx is accom- 
plished by inserting the laryngeal mirror under the soft palate and 
pressing the entire soft palate upward, the tongue meanwhile 
being drawn well out of the mouth with a napkin held between the 
thumb and index finger of the surgeon's left hand (Fig. 19). The 



THE EXAMINATION OF PATIENTS. 15 

light is now thrown upon -the face of the mirror and thus the interior 
of the larynx may be observed during respiration and phona- 
tion. It will be found that during inspiration the cords open widely, 
but when the patient phonates "A" as in "HA" or "E" as in "HE" 
the cords approximate in the median line (Fig. 20). The laryngeal 
image must be quickly observed, as most patients are intolerant of 
prolonged manipulation of the larynx. Before introducing a throat 
mirror it should be warmed over a flame or immersed in hot water. 
In making laryngeal examinations it is necessary to note the ap- 
pearance of the epiglottis with regard to its color, position, ulcera- 
tion or swelling; likewise the arytenoids, aryepiglottidean and glosso- 
epiglottic folds. Attention is then directed to the laryngeal ventricles 




Fig. 18. — Anatomical conformation of the mouth and pharynx. 1, ■ 
Palate. 2, Tongue. 3, Posterior wall of pharynx. 4, Uvula. 5, Anterior 
pillars. 6, Posterior pillars. 7, -Tonsils. 

and the true and false cords; meanwhile the motility, color and 
elasticity of the cords are noted, and the presence or absence of nodes, 
crusts, foreign bodies and new growths is observed. Looking beyond 
the cords, it is sometimes possible to observe several rings of the 
trachea and even its bifurcation. 

Throat mirrors which admit of boiling are now manufactured, 
hence they may be kept sterile. A variety of sizes are requisite and 
numerous angles and bends in the shaft or mirror attachment will 
be found applicable to the great variety of throats. About five 
variations in diameter of mirrors (Fig. 3) from half to one inch will 
suffice. 

Recently an instrument has been devised by Hays (Fig. 494), 
which permits of direct inspection of the entire rhinopharynx and 
also the larynx, with the patient's mouth closed. The instrument is 
a cystoscope modified for use in this region and is known as Hays's 



16 



GENERAL CONSIDERATIONS. 



pharyngoscope. The light is furnished by* two small electric bulbs, 
and the surgeon's eye placed to the telescope views the inspected 
field. The invention is quite recent and as yet the instrument has 
only a value as a diagnostic aid, but is especially useful in examin- 
ing bedridden persons. 




idely separated. 



Additional Information. — In addition to the information thus 
far obtained by means of inspection, there are other procedures 
necessary to the complete examination of the ear, nose and throat. 

Ear. — Among these may be mentioned inflation of the ears 
through the Eustachian tube. The chief methods employed for this 
purpose are Valsalva's, Politzer's and direct inflation by means of 
the Eustachian catheter. 



THE EXAMINATION OF PATIENTS. 17 

In Valsalva's method the patient is instructed to firmly grasp 
the nose between the thumb and forefinger to prevent the escape 
of air ; then with the mouth closed the air is forced from the 
lungs into the nasal chambers and pharynx. Its normal avenue of 
escape being shut off, and the Eustachian tubes offering the least 
resistance, they open and the air rushes into the tympanic cavity. 

This method may be conveniently used while the ear is under 
inspection, and the presence of a perforation can occasionally be 
detected when otherwise it would escape observation. 

In Politzer's method a cone-shaped nose-piece connected to a 
compressible rubber bag by rubber tubing is fitted snugly into one 
nostril and the other nostril is closed by the index finger of the 
physician. The patient is then instructed to freely puff air into his 
cheeks without allowing it to escape, or he is instructed to perform 
the act of swallowing either with or without water, or he is told to 




Fig. 20. — The laryngeal picture — cords in apposition. 

repeat rapidly the letter "K," and while so engaged the surgeon 
compresses the rubber bag and forces air through the Eustachian 
tube into the tympanic cavity. 

The most efficacious and exact method is Eustachian cathe- 
terization. The Eustachian catheter (Fig. 3) should be constructed 
from pure silver, and be about eight inches in length and the distal 
end curved sufficiently to rotate snugly into the Eustachian orifice. 
Opinions vary as to whether the curve should be long and gradual 
or sharp. The advantage of pure silver in its construction is found 
in the flexibility of the instrument to meet the variations made 
necessary by intranasal irregularities and digressions in faucial 
conformation. 

For purposes of diagnosis in the routine treatment of chronic 
and of some acute affections of the middle ear, catheterization 
secures the most favorable results (Fig. 21 ). It is applicable mostly 
to adults, but even young children often submit to catheterization 
with good grace. Under Favorable circumstances, with wide-open 
nares, the introduction of the catheter is unpleasant. Furthermore 
it is a painful procedure in patients whose membranes are hyper- 



18 GENERAL CONSIDERATIONS. 

sensitive, or in those with lesions which obstruct the nose. This 
should be remembered by the surgeon while manipulating the 
catheter. A reputation for gentle and painless catheterization 
brings many loyal allies. When catheterizing for the first time the 




Fig. 21. — Proper position of surgeon and patient during catheterization 
of the Eustachian tube. 1, Catheter in position. 2, Otoscope. (Diag- 
nostic tube.) 3, The Dench middle-ear vaporizer with air douche in sur- 
geon s right hand. 

patient's confidence may be gained by making a preliminary appli- 
cation of a mild solution of cocaine and adrenalin chloride along the 
inferior nasal meatus and the Eustachian orifice. By doing this 
the tissues are both shrunken and anesthetized, and thus cathe- 
terization is made easy. It is not advisable to cocanize all cases as 



THE EXAMINATION OF PATIENTS. 



19 



a routine method. In introducing the catheter the nostril may be 
dilated with a speculum under reflected illumination, or the tip of 
the nose elevated with the surgeon's finger. The catheter tip is 
now slid along the floor of the inferior meatus (Figs. 21, 22, 24), 
and its shank held in a horizontal position until it passes through 
the choana and dips toward the nasopharynx. At exactly this 
point the author ignores the usual rules, rotates the tip outward 
and upward with slight and gentle manipulation until it engages 
in the Eustachian orifice ; or following the same method of intro- 
duction the catheter may be first carried well over into the epi- 
pharynx and then drawn forward until it is firmly in contact with 




Fig. 22. — Catheter properly introduced along the inferior meatal floor. 
The catheter is shown as it emerges into the epipharynx and is about to 
be rotated into the Eustachian orifice. 



the posterior aspect of the soft palate, from which point it is rotated 
outward to little more than a right angle and its point enters the 
Eustachian orifice. 

A favorite method of catheterization with many operators is 
to rotate the tip of the catheter toward the median line after its 
point falls into the nasopharynx, then draw it firmly against the 
posterior border of the septum itself, after which it is rotated out- 
ward slightly more than 180° ; this usually brings its point in apposi- 
tion with the pharyngeal orifice of the tube. The catheter having 
been properly inserted many operators insert the tip of a Politzer 
air-douche bag directly into the funnel of the catheter and drive a 
blast of air into the middle ear. The direct contact of the hard- 
rubber tip of the air-douche bag with the catheter, in spite of the 
greatest care, usually gives rise to more or less pain, owing to the 
movement which is imparted to the catheter while squeezing the air 
douche. Tn order to avoid this a length of soft-rubber tubing may 
be interposed between the air bag and the tip which fits into the 



2d 



GENERAL CONSIDERATIONS. 



catheter, and thus no shock is occasioned when the air douche is 
squeezed. 

The Dench middle-ear vaporizer (Fig. 21) is an admirable 
apparatus for tubal and tympanic inflation. It consists of a hard- 
rubber reservoir fitted with a stopcock, the turning- of which 
changes the current of air so that it passes directly to the catheter 
or is diverted and made to carry medicated vapor from the solution 
in the reservoir. 

In order to determine the patency of the Eustachian tube the 
diagnostic tube (otoscope) is employed. This is a section of small, 
soft-rubber tubing about 30 inches long, into each end of which is 




Fig. 23. — Faulty introduction of the Eustachian catheter. The catheter 
tip has been inserted through the middle meatus, consequently it fails to 
enter the orifice of the Eustachian tube when rotated. 



inserted a conical tip (Fig. 21), one of which is placed in the ear of 
the patient, the other in the ear of the operator during catheteriza- 
tion. The character of the sound imparted to the ear of the surgeon 
is of diagnostic value in determining the condition of the Eus- 
tachian tube. In a normal tube the current of air produces a low, 
soft-blowing sound. In stenosis of the tube the note is high-pitched 
and rough. No sound is conveyed by the otoscope when the 
stenosis is complete. A tube which contains mucus emits a bub- 
bling sound. When a perforation exists in the drum, the otoscopic 
bruit felt by the operator is like that of air coming into actual con- 
tact with his own tympanic membrane. 

Obstacles to Catheterization. — The chief difficulties which arise 
during catheterization are, first, inability to pass even the smallest 
catheter through the nasal meatus on account of septal deflections 
or spurs. When the deformity is small it is often possible to enlarge 
the space by contracting the soft tissues by applying adrenalin 



THE EXAMINATION OF PATIENTS. 



21 



chlorid; otherwise the surgical removal of the obstruction is 
indicated. 

As a substitute for such emergencies a catheter with a longer 
curve may be passed through the opposite side of the nose, and 
turned behind the posterior border of the septum into the affected 
tube. 

An annoying difficulty commonly encountered is the variation 
in the form, position and prominence of the tubal orifice. These 
difficulties are overcome by adjusting the curve of the catheter 
together with skillful manipulation, and, in extreme cases, the 
rhinopharyngeal mirror allows a visual inspection of the field. 

Whenever the Eustachian tube is found to be obstructed, a 




Catheter tip in position within the Eustachian orifice. 



Eustachian bougie should be passed through the catheter and along 
the Eustachian tube into the tympanum. 

Eustachian bougies are made of celluloid, whalebone or gold, 
and should be of sufficient length to project at least one and one- 
half inches beyond the distal opening of the catheter (Fig. 25). 

Method of Passing the Bougie. — The catheter is first intro- 
duced in the usual manner described for inflation, and air is blown 
through the tube in order that the patient's statement may be con- 
firmed by the diagnostic tube bruit and its proper position verified. 
A small-sized bougie is then passed through the catheter until its 
end comes in contact with the walls of the Eustachian orifice, where 
it produces a slight sensation of discomfort to the patient. The 
utmost gentleness must be used in forcing the .bougie through the 
Eustachian tube, in order to prevent the formation of false passages 
or lacerations of the tubal membrane. Tf an obstruction is encoun- 
tered, then gentle continuous pressure usually serves to overcome 
it. Tf not overcome after a few seconds of pressure, it is advisable 
to withdraw the bougie a shorl distance and make a second attempt. 



22 GENERAL CONSIDERATIONS. 

It is rare to find an obstruction which cannot eventually be over- 
come. In obstinate cases it may become necessary to employ the 
electric bougie, perfected by Duel. As the bougie approaches the 
tympanic cavity the patient usually experiences a bubbling sound. 
Occasionally the operator is able to see the dark outlines of the 
bougie through the semitransparent drum membrane. Even in 
normal Eustachian tubes, slight resistance is usually found when 
the bougie passes from the membranous to the bony portion of the 
tube. If care is not exercised in properly adjusting the catheter 




Fig. 25. — Eustachian bougie passed through a catheter, and projecting 
about 1^4 inches (about the length of the Eustachian tube) from the 
distal end. 

before attempting to pass the bougie, the latter instead of engaging 
the Eustachian tube may pass down along the pharyngeal wall 
(Fig. 22). Whenever this occurs the catheter immediately rotates 
downward away from its position in the tubal opening. 

Dangers of the Eustachian Bougie. — As before stated, great 
care must be exercised in order to prevent the formation of false 
passages or abrasions in the tubal membrane. If inflation is prac- 
tised after such an accident there is danger of forcing air into the 




Fig. 26. — Siegel pneumatic speculum. 

submucous tissue, and this evokes alarming emphysema. Emphy- 
sema from this source is immediately relieved by puncture at any 
convenient point. The distance traversed by the bougie must be 
carefully gauged, either by markings or by previous knowledge 
gained by comparing the proportionate lengths of the bougie and 
catheter; otherwise the bougie might be forced across the tympanum 
and made to perforate the drum membrane. Bougies should be 
inspected at frequent intervals and discarded upon the slightest 
evidence of weakness at any point, in order to prevent accidental 
breaking of a small segment while within the lumen of the tube. 



THE EXAMINATION OF PATIENTS. 23 

Siegel Pneumatic Speculum. — In order to ascertain the mobility 
of the drum membrane and ossicles a suction or pneumatic specu- 
lum is employed. Two well-known varieties are in general use, the 
Siegel and the Delstanche. 

The Siegel speculum is a modification of the usual aural 
speculum, so constructed that when snugly inserted (Fig. 26) into 
the aural meatus its interior is rendered air-tight by means of an 
oblique glass window covering the distal end, through which the 
movements of the drum may be observed. The speculum is fitted 
with a compressible rubber bulb attachment which enables the 
surgeon to exhaust or compress the column of air in the external 
auditory canal. A lens is sometimes provided which serves to 
magnify the drum and its landmarks, and gives a clearer view of 
its mobility. By compressing and relaxing the bulb, the long 
process of the malleus and the drum are forced fully inward and 
outward unless they are bound down by adhesions. 

The functional tests of hearing are fully described in Chapter 
IV. For a description of translumination and radiography of the 
nasal accessory sinuses the reader is referred to Chapters XXXVII 
and XXXVIII. 



CHAPTER III. 

THE PHYSIOLOGY OF HEARING. 

To better understand the physics of sound production, trans- 
mission and perception, we will briefly allude to some of the most 
authentic laws relating thereto. Sound is a physiological phe- 
nomenon or sensation, induced in the mechanism of hearing by the 
vibratory motion of matter. Any elastic medium is capable of con- 
ducting sound vibrations, and their intensity varies inversely as the 
square of the distance from the ear, not depending on the density 
of the air in which the sound is heard, but on that in which it is 
generated. The intensity is directly proportional to the square of 
the maximum velocity, and also to the square of the amplitude of 
vibration. 

The intensity of sound does not weaken according to the law 
of inverse squares provided the sound is confined in tubes, inasmuch 
as the walls of the tubes prevent loss by diffusion. 

The velocity of sound depends on the elasticity, density, and 
somewhat on the molecular structure of the medium through which 
it is transmitted, and it is directly proportionate to the square root 
of the elasticity of the air, and inversely proportionate to the square 
root of the density of the air; hence, velocity is not affected by 
changes in density if the temperature remains the same, as the 
elasticity and density vary in the same proportion but act differ- 
ently. The velocity of sound in water is four times its velocity in 
air, in iron nineteen times, and in pine wood ten times, because the 
elasticity of these media is vastly greater in relation to their density 
than is the elasticity of air in relation to its density. The disturb- 
ance of bodies by any form of impact or friction produces vibration 
in the molecules of such bodies ; this results in sound. Variations 
in the quality or pitch of sound depends upon the regularity and 
rapidity of the vibrations. If sonorous vibrations are rapid and 
occur at regular intervals, they are perceived by the normal ear as 
musical sounds. It has been proven by experiment that less than 
16 double vibrations per second are received individually. The 
rapidity of the vibrations in order to procure musical sounds must 
be between 16 D.V. and 32,500 D.Y. per second. When the vibra- 
tions are irregularly repeated, or are below 16 double vibrations 
per second, the resultant sound is perceived by the ear as a noise. 
Depending upon the rate of vibration, the note is of low or high 
pitch, until the vibrations follow each other too rapidly for the ear 
to perceive them. 

The limits of sound perception are called the tone limits of the 
ear, and range from about 16 double vibrations per second to about 
35,500 double vibrations per second. These figures are only ap- 
proximate, as many ears can distinguish sounds below and above 
the figures given. 
(24) 



THE PHYSIOLOGY OF HEARING. 25 

The sound conducting or transmitting apparatus is that portion 
of the hearing organ from the concha to the labyrinth. 

The perceptive or analytic portion of the organ of hearing 
consists of that part of the ear extending from the labyrinth to the 
brain, and includes the labyrinth. Corti's organ, auditory nerve, 
and the distribution of the auditory nerve fibres to their respective 
brain centres. It may be remarked in passing that the peri- and 
endo- lymph circulating in the labyrinth belong to both parts of the 
hearing apparatus, since these fluids act as agents which assist both 
in conducting and in receiving wave impulses. 

Individual sounds or musical notes, as ordinarily produced, are 
almost invariably accompanied by overtones of higher pitch which 
modify the timbre of the fundamental note. Harmonics (over- 
tones) are more noticeable in the lower portions of the musical 
scale, and this should be remembered as a fact of considerable 
import in connection with the functional examination of the ear. 

We record the various rates of vibration as follows: (C~ 2 , C" 1 , 
C, Ci, Co, C 3 , C 4 , etc.). This means that C" 2 , having 32 double 
vibrations (D.V.) per second, is one octave below C" 1 , having 64 
D.V. per second, and this in turn is an octave below C, which has 
128 D.V. per second. Whenever two notes are an octave apart they 
differ intheir rates of vibration in the proportion of two to one. 
Any one or all portions of the conducting apparatus may become 
diseased, and it is the purpose of the hearing tests to differentiate, 
localize and diagnosticate the nature and degree of the lesion. 

To illustrate : A sound wave, striking the concha, collected 
and reflected by its folds, travels through the column of air in the 
external auditory canal and impinges upon the membrana tympani. 
This starts a molecular movement in the ossicles, which, in their 
turn, transmit this impulse to the endolymph, compressing and then 
rarifying it, sensations which are perceptible at various parts of 
Corti's organ and interpreted in the remainder of the perceptive 
apparatus. The impulse thus received is carried, as every impulse 
received by a specific nerve is. carried, to its proper receptive and 
analytical centre in the brain, and is there recognized as a given 
sound. In order that this physiological function shall be properly 
carried out it is necessary that the ear in all its parts be normal. 



THE SOUND- CONDUCTING APPARATUS. 

The Auricle (Pinna). — The functional value of the auricle is 
that of a collecting appendage — to collect the sound waves — and 
while its value as such is not very great, it undoubtedly exercises 
considerable influence in directing the sound waves toward the 
meatus. This peculiarity is more marked in- animals than in man. 
Of the different depressions in the pinna that of the concha has 
been proven to have the most important bearing upon the act of 
hearing. 

The acuteness of hearing is slightly influenced by the angle at 
which the auricle is attached to the head, but the direction from 



26 GENERAL CONSIDERATIONS. 

whence a sound emanates cannot be accurately determined except 
by binaural hearing. The tragus acts as a reflector for the sound 
collected and reflected from the concha, and from it the sound 
caroms into the external auditory meatus. The muscles attached 
to the human pinna have practically no influence in aiding in the 
collection of sound waves. 

The External Auditory Canal. — The external auditory canal 
conveys the sound waves to the tympanic membrane. Owing to 
the exaggerated concavity of the posterior end of the cartilaginous 
meatus and that of the anterior-inferior portion of the osseous, canal, 
a considerable portion of the sound waves are deflected from their 
course, and thus do not directly strike the surface of the drum 
membrane. 

Experiments show that the width of the auditory meatus has 
but slight effect on sound perception. The external auditory canal, 
like all tubes, has an intrinsic note of its own, but unless the canal 
is filled with fluid, or its membranes have become much thickened, 
this intrinsic note is difficult of demonstration, for it lies far above 
the range of the speaking voice. 

The Membrana Tympani. — The drum membrane has two func- 
tions. It not only protects the middle ear from atmospheric, 
mechanical influences and bacterial invasion; but it also acts as a 
drumhead to receive and transmit sound waves to the ossicular 
chain. Being only slightly elastic, it is stiff enough to lessen the 
effect of after-vibrations. Its large size in proportion to that of the 
stapes footplate is a mechanical advantage for increased power 
transmission. 

Like the auditory canal, its intrinsic note exerts an unappre- 
ciable influence upon the sense of hearing, and the drum therefore 
can receive and transmit simultaneously tones varying in intensity, 
in pitch and in velocity. A similar principle is observed in the 
artificially constructed diaphragms such as are used in the Edison 
and Victor phonographs ; the most complicated combinations of 
sound are simultaneously transmitted. 

According to Helmholtz, the funnel shape of the drum increases 
its power of resonance and mechanically augments the force trans- 
mitted to the malleus. Mach and Kessel observed that the greatest 
excursion of the membrane is obtainable in its posterior segment. 

The Ossicles. — The vibrations of the membrana tympani 
induced by sound waves are now believed to be transmitted to the 
labyrinth, chiefly through the ossicular chain, although to some 
extent they reach the labyrinth through the medium of the air con- 
tained in the tympanic cavity and the fenestra rotunda. 

The experiments of Politzer give considerable weight to his 
contention that the ossicles vibrate as whole bodies with extensive 
amplitudes, by the action of the sound waves upon the drum mem- 
brane, and that proportionately the amount of vibrations of the 
ossicles depends largely upon the mechanism of their joints. 

By further experiments the same author demonstrated that 
when the air is condensed in the tympanic cavity a considerable out- 



THE PHYSIOLOGY OF HEARING. 27 

ward excursion of the membrana tympani with the handle of the 
malleus takes place, and a distinct motion of the articular surfaces 
of the malleus and incus is visible, while the excursions of the long 
process of the incus are trifling. Helmholtz emphasizes the impor- 
tance of the peculiar mechanism of the malleo-incudal articulation, 
wherein with the inward excursion of the malleus its cog catches 
that on the body of the incus, forcing the latter to follow in turn. 
On the other hand, with the outward excursion of the malleus its 
cog unhooks itself from the incus, thus allowing the former to make 
a wide excursion outward ; meanwhile the incus and stapes move only 
slightly. This principle serves as a protection against the injurious 
influences of violent concussions upon the drum membrane, and in 
like manner shields the labyrinth from excessive intratympanic 
pressure induced by violent inflation through the Eustachian tube. 
The relative range of motion attributable to the ossicles is roughly 
estimated in the following proportions : Stapes 1, incus 2, malleus 4. 

Over-vibration of the ossicular chain is prevented, in large 
measure, by the articular ligaments and by the ligaments and the 
folds of mucous membrane which connect them with the walls of 
the tympanum. According to Rieman and Helmholtz, these liga- 
ments and folds and the ossicular muscles maintain the necessary 
tension between the drum and the ossicles for a uniform reception 
and conduction of the various sound waves. 

Tympanic Muscles. — The mobility of the ossicles is directly 
modified by two muscles which regulate the degree of tension 
between the ossicles, drum and labyrinth. The tensor tympani 
muscle, innervated through a branch of the fifth nerve, is attached 
to the manubrium, and on contraction draws the ossicles inward 
and upward, tensities the drum membrane, crowds together the 
ossicular articular surfaces, forces the stapes footplate into the 
oval window and increases the intralabyrinthine pressure. 

The stapedius muscle, innervated through the seventh nerve, 
antagonizes the mechanism described above, since by its traction 
the drum membrane is relaxed, the stapes footplate is rotated out 
of the oval window, the incus and malleus are pushed slightly 
outward against the drum membrane, and the tension in the 
labyrinth is diminished. Politzer maintains that the chief func- 
tion of these muscles is to relieve alterations in the position and 
tension of the ossicular chain, and to protect the labyrinth from 
sudden condensations or rarifications of the air in the middle ear 
or external auditory meatus ; hence, they regulate the degree of 
tension of the hearing apparatus. 

The Eustachian Tube. — The Eustachian tube is chiefly con- 
cerned in the two important functions of ( 1 ) ventilation and con- 
densation of atmospheric pressure, and (2) drainage of the middle- 
ear cavities. 

A consideration of the action of (lie muscles attached to the 
pharyngeal end of the Eustachian tube is important, for the normal 
pneumatic balance in the middle ear is dependent on their efficacy 
as openers of the Eustachian tube. Experiments have conclusively 



28 GENERAL CONSIDERATIONS. . 

proven that the walls of the Eustachian tube during quiescence 
are in the main in contact throughout, and that the act of swallow- 
ing is the chief agency by which the air balance of the middle ear is 
maintained. The tensor palati and the levator palati muscles, both 
of which are concerned in the act of swallowing, possess the further 
function of increasing the patency of the Eustachian tube during 
contraction as a result of their area of attachment to its fibrocarti- 
laginous orifice. When at rest the cartilaginous portion of the tube 
becomes permeable as a result of even a slight increase in air 
pressure. 

This is especially true if the intratympanic pressure is raised, 
for the tube permits of air transit toward its pharyngeal mouth 
with more facility than in the opposite direction (Fowler). 

It can be seen readily that the combined action of these 
muscles greatly increases the calibre of the inner end of the tube, 
and that the act of deglutition brings this combined action into 
play as often as it is repeated, so that under normal conditions the 
air balance in the middle ear is so frequently adjusted that the 
membrana tympani and middle-ear structures are not disturbed 
from their normal equilibrium. 

Considered pathologically, the permeability of the Eustachian 
tube is in close relation to the hearing function. Inflammatory 
swelling and thickening of the tubal mucosa, accumulations of 
mucus within its calibre, tend to induce rarification of the air con- 
tained in the tympanic cavity and consequent retraction of the drum 
membrane, tinnitus and hardness of hearing. 

A partial vacuum may also occur in the middle ear because 
of nasal obstruction, inasmuch as with this condition combined 
with deglutition the tube is opened and the air in the nasopharynx 
becomes rarified, and this rarification necessarily affects the middle 
ear. Rarification of the air in the middle ear, besides causing con- 
gestion and exudation, allows the atmospheric pressure in the 
external auditory meatus to carry the drum and ossicles inward, 
and thus the stapes crowds against the oval window. 

Fowler has shown, by a series of interesting experiments, that 
the normal air tension in the middle ear is slightly above atmos- 
pheric pressure, especially after each act of swallowing, and he also 
claims that with each deglutition there is a tensification of the 
tensor tympani muscle to prevent disturbances in sound trans- 
mission and possible trauma to the conducting mechanism. 

Fowler's Experiment. — At first sight this may appear to be a 
modification of Valsalva's or Toynbee's experiment, but as its per- 
formance is different from either of these and its results opposite 
to the latter, it w r ould appear that the experiment is quite distinct. 

While the nostrils are tightly closed by pinching them together 
with the thumb and forefinger as near their free borders as pos- 
sible, gently increase the air pressure in the nose and nasopharynx 
by attempting to expire through the nose, and without letting up 
on this pressure execute the act of swallowing. The result will be 
the inflation of both middle ears. This is brought about by the 



THE PHYSIOLOGY OF HEARING. 



29 



Opening of the Eustachian tubes during the increased nasopharyn- 
geal air pressure due to the patient's efforts and to the ascent of 
the soft palate. 

During the second stage of deglutition a negative pressure is 
avoided because the primary increase in pressure and the bulging 
of the elastic lateral walls of the nose supply a sufficient amount of 
air to enable the descent of the~soft palate to occur without creating 
a vacuum in the nasopharynx. 

This method is of value because it accomplishes the inflation 
of the middle ears in' a more physiological manner than any method 
which does not necessitate the use of instruments. In selected 
cases it may be used by the patient for regular inflation. To 
remove all possibility of harm Fowler uses a small rubber balloon 
attached to a nose piece (Fig. 27). If the patient closes one nostril 
and inserts the nose piece tightly into the other, he can automati- 
cally inflate his ears by distending the bag by filling it with air 




Fig. 27. — Fowler's middle-ear inflation apparatus. 

through his nose and then swallowing several times, or until the 
balloon has collapsed. The balloons are made of different tensile 
strengths so that any pressure desired may be brought to act on 
the Eustachian tubes during the act of swallowing. It is a peculiar 
property of these balloons that the pressure necessary for their 
inflation remains almost stationary no matter how fully they are 
inflated, and likewise during their deflation the pressure does not 
materially change until the balloon is on the point of collapse. 

SOUND-PERCEIVING APPARATUS. 

A study of the physiology of the sound-perceiving apparatus or 
internal ear necessitates a division of this portion of the hearing 
apparatus into that of: (a) the vestibule; (b) the semicircular canals; 
(c) the cochlea. 

The inward excursion of the footplate of the stapes induced by 
the sound waves carries a like impulse to the labyrinthine fluid, 
which becomes displaced in the direction of the round window, 
which is the point of least resistance, and according to Ilclmholtz 
the membrana basilaris of the cochlea is forced in the direction of 
the scaln vestibuli, where it is made extremely tense on account of 
the resistance encountered at the cochlear apex. 

The exact function of the various structures of the labyrinth 
is not yet fully known, but it may be stated as the general opinion 



30 



GENERAL CONSIDERATIONS. 



of physicists that the vestibular apparatus is chiefly instrumental in 
controlling bodily equilibrium (Fig. 28). 

The otoliths are supported in the medium within the utricle 
and saccule, upon delicate hair-like projections, and, according to 
Breuer, with each forward movement or inclination of the head they 
tend to retain their normal position and thus bend the hairs which 
are their support, thereby inducing the specific sensations in the 
.brain centres, the interpretation of which gives to the individual a 
conception of the relation of the head to the line of gravity. 

The Semicircular Canals. — Contrary to the belief of the earlier 
writers that the semicircular canals by their peculiar arrangement 
enable the ear to locate the direction of sound waves, it is now 
known that they have no influence relating to the perception of 
sound. On the other hand they constitute the organ of co-ordi- 
nation of the movements of the body. The tests of Barany and 



WZmr 




Fig. 28.— Showing thick membrana basilaris near the 
lower end of the basal coil. (From Shambaugh's collection. 
With permission.) 



others, hereinafter described (see Chapter XXIII), explain more 
fully the function of the semicircular canals. 

Cochlea. — Corti's cells (ciliated), about 2000 in number, are 
generally believed to constitute the terminal apparatus of the 
acoustic nerve. The cochlea, therefore, constitutes the organ for 
the reception and differentiation of sound waves, which are in turn 
conveyed through the auditory nerve trunk to the cortical centre 
of hearing. Many investigators believe the latter to be situated in 
the posterior two-thirds of the first and second temporal convolu- 
tions. Upon reaching the acoustic centres the waves are inter- 
preted as sound. 

Helmholtz's theory of sound analysis assumes that the basilar 
membrane of the cochlea contains a considerable number of sound- 
ing boards or resonators which are attuned to certain tones. These 
resonators are set into action by the aqua cotunnii, and the vibra- 
tions thus produced are transmitted to the brain as impressions of 
sound by the nerve fibres corresponding to these sounding boards. 

Shambaugh, whose researches in the anatomy of the labyrinth 
of the ear have given him an intimate acquaintance with the details 
of the complicated structure to be found in the inner ear, has formu- 



THE PHYSIOLOGY OF HEARING. 



31 



lated the following conclusions regarding the physiology of the 
cochlea : — 

1. The end organ in the cochlea, the so-called organ of Corti, 
is the mechanism whereby the physical impulses of sound waves 
are transformed into the nerve impulses which result in tone 
perception. 

2. The particular structure of the organ of Corti in which this 
transformation from a physical to a nerve impulse is accomplished 
is the hair cell. 

3. The stimulation of these hair cells is brought about by an 
interaction between the projecting hairs and the overhanging mem- 
brana tectoria. 




Fig. 29. — Mt, Membrana tectoria about one-half turn 
from the lower end of the basal coil. (From Shambaugh's 
collection. With permission.) 



4. While Helmholtz, and those who have followed him, 
advocate the hypothesis that the membrana basilaris (Fig. 28) is 
thrown into vibrations by the impulses of sound w r aves passing 
through the fluids in the labyrinth, in this way carrying the hair 
cells up against the under surface of the membrana tectoria (Fig. 
29) and resulting in their stimulation, Shambaugh concludes 
that the membrana tectoria is the active agent which, by respond- 
ing to the impulses in the endolymph, vibrates and thus brings 
about the stimulation of the underlying hair cells. 

His reasons for placing the active agent in the membrana 
tectoria rather than the membrana basilaris are stated as follows: 
In the first place, the three end organs found in the labyrinth of 
the ear, the macula acnstica in the vestibule, the crista acustica in 
the semicircular canals, and the organ of Corti in the cochlea, all 
have a common origin in the primitive otic vesicle. They are all 
three constructed on exactlv the same fundamental plan, consisting 
of hair-bearing cells and a superimposed epithelial structure. This 



32 



GENERAL CONSIDERATIONS. 



overhanging epithelial structure in the macula acustica is the 
otolith membrane, in the crista acustica it is the cupula, while in 
the organ of Corti it is the membrana tectoria. Since the stimula- 
tion of the hair cells in the macula acustica, as well as in the 
crista acustica, is brought about by a movement of the super- 
imposed epithelial structure, the otolith membrane and the cupula 
respectively, it is rational to conclude that the stimulation of the 
hair cells in the organ of Corti is also brought about by the move- 
ments in its superimposed epithelial structure, namely, the mem- 
brana tectoria. In the second place, he has found that the mem- 
brana basilaris is incapable of performing the role of a vibrating 
structure, attributed to it by Helmholtz and those who have fol- 
lowed him, for the following anatomical reasons: The membrana 




Fig. 30.— Mi, membrana tectoria near the apex of the cochlea. S H, streifen 
of Henson. (From Shambaugh's collection. With permission.) 

basilaris disappears as a possible vibrating structure near the lower 
end of the basal coil at a point where the organ of Corti is still 
found. The radiating fibres of the membrana basilaris toward the 
lower end of the basal coil, where they are becoming shorter instead 
of becoming thinner, as they should do in order to fulfill the physi- 
cal requirements of string resonators, in reality are found to become 
thicker as the end of the coil is approached. Again, a fundamental 
principle in the Helmholtz theory is that each radiating fibre of the 
basilar membrane must always respond to the same tone. This is 
rendered impossible because of a blood-vessel attached to its under 
surface, the dilation and contraction of which must cause the several 
radiating fibres to respond at different times to tones of different 
pitch. For these fundamental anatomical reasons Shambaugh 
concludes that the membrana tectoria is not only the logical struc- 
ture for responding to sound impulses in the endolymph, but that it 
is anatomically impossible for the membrana basilaris to fill this 
role. 

5. The response which the membrana tectoria gives to the 
impulses of the various tones must be such as to account for the 
following phenomena connected with tone perception : — 



THE PHYSIOLOGY OF HEARING. 33 

(a) The phenomenon of tone analysis, the faculty which the 
ear possesses of analyzing into its component parts complex tone 
impulses. 

(b) The so-called secondary phenomena of tone perception, i.e., 
beats, summation tones, difference tones^ etc. 

(c) The occurrence of certain pathological phenomena, espe- 
cially the phenomena of tone islands and of defects in the midst of 
the tone scale. 

6. The only possible action of the membrana tectoria in 
responding to the impulses from the various tones, that will 
account plausibly for the above phenomena, is that it responds in 
different parts of the cochlea (Fig. 30) to tones of different pitch, 
at the apex for the low tones, toward the base of the cochlea for 
the tones higher in the scale. Such a response would be in the 
nature of physical resonance. 



CHAPTER IV. 
FUXCTIOXAL EXAMINATION. 



THE TESTS FOR HEARING. 

Functional examination, by which is meant the application 
of the approved methods for testing the hearing, is a procedure of 
importance in determining the degree of impairment or perversion 
of hearing. The value of these tests in the realm of diagnosis 
is to determine the location of pathological changes, and to record 
the progress of treatment. When other methods of examination 
give negative diagnostic results, the functional tests usually deter- 
mine whether the cause of the disturbance of hearing has its seat 
in the sound-conducting or in the sound-receiving apparatus. 

Diminished auditory function due to disease of the sound-con- 
ducting mechanism is indicated by a diminution or loss of aerial 
conduction, together with either normal or accentuated bone con- 
duction. On the other hand, diminished function of the sound- 
receiving mechanism will be indicated by partial or complete loss 
of bone conduction and of aerial conduction as well. Unilateral 
deafness, when due to disease of the conducting apparatus, will 
show either normal or increased bone conduction, with partial or 
total loss of aerial conduction upon the diseased side. A descrip- 
tion of the various tests will serve to elucidate these statements. 

Impairment of the conducting apparatus is characterized by 
the' loss of power to hear the lower tones of the musical scale. 
Impairment of the receiving apparatus is characterized by loss of 
power to hear the higher tones of the scale. 

The tests are conducted (1) to determine the degree of per- 
ception of sound waves carried to the membrana tympani 
(aerial conduction) ; (2) to determine the degree of perception of 
sound waves transmitted to the auditory apparatus through the 
cranial bones (bone conduction) ; (3) to enable the examiner by a 
process of comparisons to localize the lesion and to record the 
degree of impairment of the hearing function. 

The Watch Test. — Watches differ widely in the pitch and 
intensity of their tones, hence they are inaccurate in results and 
therefore unsuitable as a routine method of testing the hearing 
function. When no other means of testing is at hand the watch 
test should be emploved and the results recorded. The record is 
made as follows: The distance in inches which the watch in use 
is heard by the normal ear is recorded as the denominator, and the 
distance heard bv the impaired ear as the numerator. If the normal 
distance should be 40 inches and the patient's hearing distance only 
20 inches, the record for the watch would be 2 %a- 

The Voice Test. — The chief value of the voice test is to enable 
the examiner to determine the hearing function for conversation. 
(34) 



THE TESTS FOR HEARING. 35 

In this connection it may be stated that under normal conditions 
all individuals possess hearing power far in excess of the require- 
ments for ordinary conversation ; hence, the diminution of the 
hearing distance may be considerable and still in no wise affect the 
individual's conversational capacit)^. It is commonly observed that 
the first sign of gradually approaching deafness is the difficulty of 
comprehending the language of public speakers, or to hear general 
conversation carried on by a company of individuals. In this con- 
nection it may be noted that the vowels are heard more distinctly 
than the consonants, and that the pitch, timbre, quality and carrying 
power of individual voices vary widely. 

The investigations of Wolf show that the human speech pos- 
sesses a compass of about eight octaves. 

The voice test should be conducted in the following manner : 
The patient should be placed at one end of the room. The 
examiner, taking his place at the opposite end, conducts the test. 
It is recommended that the whispered voice should be employed in 
all cases except severe forms of deafness for the reason that, as 
stated by Wolf, this test is more certain inasmuch as ordinarily 
the volume of tone is thus diminished by the speaker, and the 
waves of sound reach the ear with much less intensity than in loud 
speech. The patient is instructed to block off the canal of the oppo- 
site ear by pressing the moistened finger tightly into the external 
meatus. He is further instructed to repeat what he hears and to 
avoid visual observation of the examiner. 

It is further recommended that the examiner establish a definite 
system of numerals rather than elaborate combinations of vowels 
and consonants, with sufficient variations to avoid frequent repeti- 
tion. For instance — the examiner at the end of inspiration may 
whisper the number 58, 44, or 88, gradually approaching the patient 
and repeating the numbers until the patient hears and repeats them. 
The distance in feet heard by the patient is then marked in the 
proper column in the examination chart (Fig. 9). In like manner 
the opposite ear is then examined, using a different set of numerals. 

The Acoumeter. — A more accurate and reliable method of test- 
ing the hearing is found in using the Politzer acoumeter (Fig. 31), 
which, when properly constructed, produces a fixed tone of equal 
pitch and amplitude. Unfortunately the instrument makers do not 
always construct these instruments according to the rules laid 
down by Politzer, namely, that all the parts of every instrument 
should be exactly alike and all give a similar note in pitch and 
amplitude. 

The acoumeter is heard normally at about forty-five feet. If 
a patient under examination should be able to hear it only six feet, 
the record should read (hearing for acoumeter equals %.->)• If the 
acoumeter is not heard at all aerially, but is heard on contact, the 
record for the numerator should be contact -f- C. 

The tone of a properly constructed acoumeter should corre- 
spond to C 2 , and can be compared to a watch with an extremely 
loud tick. This tone is mechanically adjusted by drilling out the 



36 GENERAL CONSIDERATIONS. 

cylinder. In cases wherein the acoumeter is not heard by aerial 
conduction the round metal plate may be attached thereto and 
placed in close contact with the tissues nearby the external ear, 
when the tone may be perceived. It is important that the patient's 
head should be so turned that the sound waves will pass in a direct 
line from the acoumeter along the external auditory canal. After 
some experience on the part of the examiner he becomes able to 
measure the distance heard by the acoumeter with sufficient accu- 
racy, but a more exact system is tbat wherein the space usually 
employed for hearing tests is measured off upon the floor or wall. 

The ears should be examined separately, and the opposite 
meatus tightly shut off with the moistened finger during each 
examination. The test is more accurate when the instrument click 
is commenced at a distance beyond the range of hearing and 
gradually moved toward the ear until heard. In some instances 




Fig. 31. — Politzer's acoumeter 



it is necessary to cover the eye of the patient during this procedure 
in order to eliminate the element of imagination. 

The perception of sound varies greatly in the same subject, 
depending upon atmospheric conditions, the state of the mucosa of 
the upper respiratory tract, and the variations in the physical and 
psychical condition of the individual. The hearing distance is also 
materially influenced by extraneous noises of all kinds. These 
variations are often noted upon examinations at different periods 
of the same day. Bezold and Politzer noticed that when there is 
an increase in hearing distance for the acoumeter there would 
probably be a corresponding increase in perception for speech, but 
this is not always true for the watch test. 

It is commonly observed that a marked difference exists be- 
tween the perception of speech and that of various musical or 
clicking sounds. Hence many individuals who exhibit marked defects 
in the perception of noises other than the human voice are able to 
converse, even after marked dimness of perception for other noises 
has become apparent. Unfortunatelv. the converse is also true. To 
accurately determine the condition of the auditory function repeated 
tests must be made, uniform results being necessary for definite and 
reliable conclusions. 

The Tuning-fork Test. — The tuning fork possesses a special 



THE TESTS FOR HEARING. 37 

diagnostic value in that by means of it and by comparison of the 
conducting power of the cranial bones with that through the air, 
the examiner is enabled to differentiate middle ear from labyrin- 
thine affections. The power of perception of the human ear under 
normal conditions ranges from 16 to 48,000 double vibrations per 
second. These may be recorded as the extreme limits, inasmuch 
as Howell 1 claims that the majority of adults are. unable to perceive 
vibrations below 24 or above 16,000 per second. The hearing func- 
tion may become defective either in the lower tones, or, per 
contra, the higher, or, for that matter, in isolated sections of the 
scale. Hence it becomes important to record in each instance that 
portion of the musical scale which has become impaired or defective 
as a result of disease. 

While many authorities consider it important for diagnostic 
purposes to employ a complete octave series of tuning forks in 




Fig. 32. — Set of Hartman's tuning forks. 

order to secure absolute accuracy, a series of five forks constructed 
by Hartmann (Fig. 32) is sufficient, in the majority of cases, 
to make a fairly accurate diagnosis. Bezold recommends a con- 
tinuous range of forks constructed by Edelmann, comprising 10 
tuning forks, 2 pipes and the Galton whistle (Fig. 33), the forks 
being equipped with movable clamps for varying the range of tones. 
For ordinary diagnostic purposes in testing the perception for the 
middle, the lower, and the upper tones, at least three tuning forks, 
C, C 2 and C 4 should be employed in each individual case. When- 
ever the upper tone limit is above the C 4 fork of the Hartmann set 
the Galton whistle may be substituted. 

The tuning fork C 2 — 512 vibrations per second, corresponding 
to the middle C of the scale — is the one heard longest by 
the ear. A difficulty in the use of the fork test is to maintain 
a standard force to produce the vibrations, inasmuch as the 
intensity and amplitude depend upon this force. In order to 
accomplish tin's, Lucae constructed a fork witli a hammer attach- 
ment. The Lucae fork is so arranged that by a mechanical device 
the hammer strikes the fork through the agency of a spring, 



American Text-book of Physiology, 1896. 



38 GENERAL CONSIDERATIONS. 

thus causing a uniform striking force and consequently a uniform 
series of vibrations. The employment of such a fork gives a 
standard by which comparative results are obtained. The practical 
and valuable applications of the tuning-fork tests for diagnostic 
purposes are found in the following tests : — 

(a) The Schwabach Test. — Schwabach observed that when the 
sound-conducting apparatus becomes impaired as a result of disease 
or obstruction of the external or middle ear. the vibrating tuning 
fork is heard with a diminished intensity and for a shorter period 
of time, aerially, and with an increased intensity and for a longer 
period of time, by bone conduction. He further observed that both 
aerial and bone conductions of sound are diminished in diseased con- 
ditions of the auditory nerve. The Schwabach test is based on these 
observations. 

In conducting the Schwabach test a comparison of the percep- 
tion of tone by aerial and by bone conduction is made in the dis- 




Fig. 33. — Galton whistle. 

eased ear, and the results thus obtained are compared in turn with 
results from similar tests in the normal ear. 

By reference to the author's history chart (Fig. 9) it will be 
observed that a space is arranged for recording the length of time, 
in seconds, which the fork is heard by both aerial and by bone con- 
duction for the five forks of the Hartmann series. The numerator 
represents the aerial conduction, and the denominator that of the 
bone conduction. For purposes of comparison the figures which 
represent the normal time perception for each fork in seconds have 
been given with fair accuracy, these figures having been obtained 
as the average result of the examination of 100 United States 
soldiers. (Nichols.) 

The test for bone conduction should be made by placing the 
handle of the vibrating fork directly over the mastoid antrum. A 
less reliable method of determining the duration of perception of 
tone is by comparing the time of perception of the patient with that 
of the examiner. Marked shortening of the duration of tone percep- 
tion by bone conduction indicates disease of the auditory nerve. 
Normal or increased duration of perception by bone conduction 
with diminished aerial conduction indicates diseases of the middle 
ear, or of the sound-conducting apparatus. Diminution of both 
aerial and bone conduction of sound indicates disease of the audi- 
tory nerve or a combined affection of both the perceptive and the 
conducting apparatus. 



THE TESTS FOR HEARING. 39 

(b) The Rhine Test. — The Rinne test is based upon the assump- 
tion that normally the duration of tone perception through the air 
exceeds that of the duration of tone perception through the bone. 
Therefore, if the tone of the vibrating tuning fork is perceived 
longer when held in front of the ear than when applied to the 
mastoid process, the result is recorded as a positive Rinne (Fig. 
9), and is marked as follows : -f- Rinne. But when the tuning fork 
is heard longer when applied to the mastoid process than when it 
is held in front of the ear, the result is recorded as a "negative 
Rinne" ( — Rinne). The latter may be considered indicative of 
disease of the sound-conducting apparatus. According to Rinne, in 
cases of impaired hearing whenever the duration of perception of 
the tone of the vibrating fork is longer before the ear than through 
the cranial bones (positive Rinne), we may conclude that the sound- 
perceiving apparatus is diseased. 

While the value of Rinne-' s test is somewhat limited, it may be 
employed in order to corroborate conclusions reached from other 
tests. 

(c) The Weber Test. — Weber found, by placing a vibrating 
tuning fork upon the skull of a person who had normal hearing, 
that it would be heard more distinctly in that ear the external 
meatus of which was closed or plugged. This phenomenon is 
believed to be due to amplified resonance within the external audi- 
tory canal. The test possesses a marked diagnostic value in 
unilateral deafness, following out the principle laid down by Weber, 
viz., that in any case of unilateral deafness it will be found that a 
vibrating tuning fork (preferably the C 2 , 512 D.V.) placed upon the 
median line of the skull is heard with greater distinctness in the 
partially deaf ear, whenever the cause of the deafness is situated in 
the middle or the external ear (sound-conducting apparatus) ; on 
the other hand the sound will be heard more distinctly in the sound 
ear if the cause of deafness is located in the labyrinth — sound-per- 
ceiving apparatus. In the first variety, the reinforcement of sound 
on the diseased side may become so marked that the tuning fork is 
not perceived at all by the normal ear. In bilateral deafness the 
tone may be more loudly perceived in the ear most involved. 

A positive localization of sound upon the part of the patient 
gives to this experiment its chief value. In combined affections of 
the middle ear and labyrinth the Weber test is scarcely available. 

(d) The Gelle Test. — Gelle discovered that compressing the 
column of air in the external auditory canal diminished the percep- 
tion of tone. Such compression may be accomplished by means of 
the Siegel speculum or air bag attached to a tip so shaped as to 
completely close the external auditory meatus, condensation being 
made by pressure upon the bulb. Diminution in tone perception 
results from the increased labyrinthine pressure evoked by an 
inward movement of the footplate of the stapes. Hence, Gelle's 
claim that if there is any great obstacle to sound conduction — especially 
ankylosis of the stapes — the tone remains unchanged during the 
application of the test, whereas, in labyrinthine affections, with a 



40 



GENERAL CONSIDERATIONS. 



movable stapes diminished tone perception obtains with each con- 
densation of air in the external auditory canal. 

(e) The Bing Test. — This test is employed as an aid in differ- 
entiating between affections of the middle ear and the labyrinth. 
Bing observed that, when a tuning fork placed in contact with the 
mastoid process ceases to be heard, the sound reappears upon 
tightly closing the orifice of the external auditory canal. In patients 

with marked deafness if the tone 
fails to reappear upon closure of the 
meatus, deafness must be the result 
of disease of the sound-conducting 
apparatus, and, conversely, if when 
there is severe deafness the tone re- 
appears, the deafness must result 
from disease of the sound-perceiving 
apparatus (labyrinth). 

(/) The Fowler Test.— Dr. Ed- 
mund Prince Fowler, of the author's 
staff, has devised an apparatus which 
consists of a glass resonator so con- 
structed that it will inclose the pinna 
and fit tightly against the surround- 
ing skin (Fig. 34). On this reso- 
nator is mounted, by means of a 
stout rubber tubing, a C 1 tuning 
fork, and, by a nipple on the under 
side of the bell, the apparatus is con- 
nected through rubber tubing to an 
air bag. Fowler claims that by 
means of his appliance ossicular 
ankylosis may be diagnosticated, 
and especially ankylosis of the stapes 
footplate. This latter condition is 
shown if, on air condensation, no diminution in the perception 
of the fork's note is observed. Malleo-incudal ankylosis exists 
if on rarefying the air in the external auditory meatus no diminu- 
tion of sound ensues. 

Fowler's tests are too recent to be finally passed upon, but at 
least his apparatus furnishes us with a simple method of obtaining 
phenomena similar to Gelle's. It is of special advantage in cases 
of severe deafness, for the fork mounted on a resonator is heard 
twice as loud and several times as long as a fork in direct contact 
with the scalp. 




Fig. 34. — Fowler's resonator 
apparatus. 



CHAPTER V. 

GENERAL ETIOLOGY OF EAR DISEASES. 

This chapter is introduced for the express purpose of enumerat- 
ing and defining, in a general way, the more common causes of 
aural affections. 

ETIOLOGICAL AND DIAGNOSTIC VALUE OF THE 
BACTERIOLOGY OF EAR DISCHARGES. 

Bacteriological investigation of middle-ear discharges when 
expertly conducted under proper conditions is of much value to 
the otologist. 

The most reliable results are obtained from pure cultures of 
discharge which have been drawn from the tympanic cavity through 
an intact drum membrane, by means of a long hypodermic needle, 
the external auditory canal having been previously sterilized, or 
when taken from the first gush following a paracentesis. 

The tip of the paracentesis knife rubbed upon the culture 
medium or slide immediately after withdrawal is a fairly trust- 
worthy method of obtaining a portion of intratympanic infection. 
It is sometimes possible to obtain the primary pathological micro- 
organism through a mastoid opening in those rare cases where 
mastoiditis has developed without rupture of the drum membrane. 

In chronic otorrhea the bacterial findings are of but little sig- 
nificance on account of the long-continued admixture of micro- 
organisms from without. 

The earlier published reports of bacterial findings in middle-ear 
discharge are unreliable, inasmuch as smears and cultures were 
often prepared from pus which had been contaminated with 
extraneous bacteria. 

In smear examinations the order of frequency of the various 
micro-organisms in the discharges is : The streptococcus, pneumo- 
coccus, pyogenic staphylococcus, Friedlander's bacillus, tubercle 
bacillus, diphtheria bacillus (Klebs-Lofner), influenza bacillus, 
diplococcus intracellulars meningitidis, typhoid bacillus, the bacillus 
coli communis, Neisser's gonococcus, Vincent's spirillum and 
bacillus, and the smegma bacillus. The author has reported one case 
of the latter variety in which the smegma bacillus was at first mis- 
taken for the tubercle bacillus. The patient developed mastoiditis 
which required operation. 

With the permission of Dr. Jonathan Wright, Director of the 
Pathological Department of the New York Post-Graduate Hospital, 
the author is enabled to state that, from the unpublished reports of 
examination of pure cultures of car discharges obtained in the 
manner above described, the streptococcus prevailed in the majority 
of cases. 

(41) 



42 



GENERAL CONSIDERATIONS. 



Dr. Dixon, of the Pathological Department of the New York 
Eye and Ear Infirmary, lays stress upon the unusual virulency of 
the streptococcus capsulatus, and advises early mastoid operations 
in all cases that do not immediately improve after free drainage has 
been established through the drum membrane. He and others have 
remarked that extensive destruction of the middle-ear and mastoid 
structures mark the invasion of this micro-organism, and very often 
these pathological changes take place without producing any symp- 
tom-complex by which the gravity of their attack is recognized. 
The fact that the streptococcus sometimes has a capsule is of doubt- 
ful significance, inasmuch as the stains employed for demonstrating 
it are unreliable, and the results are capricious. 

The report of Dench 1 fails to verify the observations of Dixon, 
for out of thirteen cases wherein the streptococcus capsulatus was 
found only three came to operation. 

MODE OF ENTRANCE OF PATHOGENIC BACTERIA INTO 
THE TYMPANIC CAVITY. 

1. In a vast majority of all cases of purulent otitis media the 
bacteria find entrance through the Eustachian tube. Fortunately 
the small calibre of the tube and the opposing movements of its 
ciliated epithelium tend to prevent the entrance of bacteria ; other- 
wise the ratio of intratympanic to intranasal infections would be 
much larger. 

It is more probable that the infection enters the tube under 
pressure effected by blowing the nose, sneezing, crying, in young 
children, violent coughing, vomiting, or as a result of inflating by 
means of the Valsalva-Politzer air douche or catheter. Any dele- 
terious effects arising from sea bathing and the employment of the 
nasal douche is due to the excessive blowing of the nose which follows, 
whereby pre-existing bacterial infections in the nasopharynx are 
forced into the tympanic cavity. 

In exhausting diseases like typhoid fever and tuberculosis 
there is loss of tubal tissue and interference with its muscular and 
nerve function, thus reducing the normal resistance to the entrance 
of bacteria. 

All forms of both acute and chronic infections of the upper air 
passages, especially when associated with intranasal obstructions 
or diseased tonsils and adenoids, favor bacterial invasion of the 
tympanic cavity. 

2. Infection may reach the tympanic cavity through the 
external auditory canal only when perforation or traumatism of 
the drum membrane has taken place. Following paracentesis, 
unless absolute cleanliness of the canal is maintained, secondary 
infection is almost inevitable, and old unhealed perforations in 
active suppuration become permanent gateways for secondary infec- 
tions to enter the tympanic cavity. 

1 Transactions of the American Laryngological, Rhinological and Otolog- 
ical Society, 1908, p. 201. 



GENERAL ETIOLOGY OE EAR DISEASES. 43 

3. It is possible for bacteria to enter the tympanic cavity 
through the lymph channels and blood-vessels. Barnick has 
demonstrated this in cases of miliary tuberculosis. Future investi- 
gations may show a larger percentage of cases due to infection from 
the blood and lymph channels, even of pyogenic bacteria, than is 
now supposed to be the case. 

4. Fractures of the temporal bone which communicate with 
the external world likewise permit the entrance of pathogenic 
bacteria, with extension by continuity to the tympanic cavity or 
mastoid cells. In the same manner intracranial infection may find 
entrance to the tympanic cavity by passing through the labyrinth, 
facial canal or petrosquamous suture. 



THE SIGNIFICANCE OF BACTERIAL FINDINGS IN EAR 
DISCHARGES. 

The external auditory canal contains the same micro-organisms 
that are found in the surrounding air, and it is the habitat of the 
forms of bacteria found upon the skin of other parts of the body — 
chiefly the staphylococcus albus. The tympanic cavity and the 
labyrinth, however, under normal conditions, have been found to 
be free from pathogenic micro-organisms. 

Micro-organisms found in the discharge from the middle ear are 
not necessarily the primary pathological agents, especially when 
studied in the chronic forms, or in the later stages of the acute 
form. The prevailing micro-organism found in the discharge of the 
middle ear, when culture has been made from the first discharge, 
through either paracentesis or spontaneous rupture, may be con- 
sidered as the pathological agent in the individual case. It is 
believed that the primary organism in a given case may give way 
to other forms. Funk is strongly inclined toward the belief that a 
definite grippal otitis is primarily due to the influenza bacillus, 
which, however, becomes quickly associated with or displaced by 
other organisms. 

The early stages of acute purulent otitis are usually mono- 
bacterial in character ; chronic purulent otitis is invariably poly- 
bacterial. 

The streptococcus pyogenes must be considered the most 
virulent and destructive to both soft and bony tissues. It is, unfor- 
tunately, also the most frequent micro-organism demonstrated in 
purulent middle-ear disease, while in children the pneumococcus 
is mostly in evidence. The differentiation of the streptococcus and 
the pneumococcus in the published reports is of little value, inas- 
much as the more recent investigations tend to show that they are 
variations which under certain conditions are interchangeable. 
Streptococcus invasions are always rapid, often requiring but a few- 
hours to involve the entire mastoid process. 

The pneumococcus is frequently seen. Tin's form of infection 
while not as virulent as the streptococcus is, on account of its 
peculiar characteristics, often attended with serious complications. 



44 GENERAL CONSIDERATIONS. 

This peculiarity is the tendency of a pneumococcus infection, 
wherever located, to heal rapidly, but, during the local healing 
process, the micro-organisms establish themselves in nearby spaces 
and set up a new infection, thus giving a series of infected foci, 
all producing their symptoms without any definite relations regard- 
ing time. Thus the tympanic cavity may become healed, even 
though the mastoid process is still the seat of the pneumococcic 
invasion. 

The staphylococcus is the least active and destructive agent 
found in purulent otitis media. 

Among the author's cases the diplococcus intracellulars menin- 
gitidis was observed with considerable frequency. As a type this 
infection may be considered moderately severe. 

The tubercle bacillus is rarely seen in middle-ear discharges, 
and even when present does not become absolute proof of the 
tuberculous character of the disease. The presence of the tubercle 
bacillus in scrapings from the tympanic cavity is more significant, 
especially when culture methods are employed. 

The Klebs-Loffler bacillus in purulent otitic discharge result- 
ing from intranasal or pharyngeal diphtheria is demonstrable. It 
may be the primary or causal organism, or occur in combination 
with the streptococcus or pneumococcus ; or it may be carried to 
an ear which is already infected, by means of the fingers or infected 
instruments. 

Suepfle 2 in the study of the ear discharges of 100 cases obtained 
the streptococcus in 60 per cent., the pneumococcus in 15 per cent., 
the streptococcus mucosus in 14 per cent., staphylococci in 8 per cent. 
The pneumococci and streptococci were usually found pure, but the 
staphylococci rarely so. 

His conclusions are as follows: — 

1. Otitis media with staphylococcus secretion (these cases 
look more like tubal disease) will recover. 

2. Staphylococcus and pneumococcus infections rarely cause 
complications. 

3. In cases of infection by the streptococcus mucosus the 
chances are even for recovery with or without operation. The 
streptococcus mucosus seems to have a deleterious effect upon the 
bone. 

4. The origin, course, and duration of otitis media depend less 
on the virulence of the infecting organism and more on the general 
and local diseased processes. 

Libman found in 141 examinations of the ear discharges the 
streptococcus in 88, pure in 79, the pneumococcus in 8, the strepto- 
coccus mucosus in 10, and staphylococci in 7. Of these cases there 
were 5 brain abscesses, the pus from which showed streptococcus 
3 times, colon bacillus once, and proteus bacillus once. There were 
13 cases of sinus-thrombosis in the same series in which the strep- 
tococci occurred 10 times, while in 3 cases no bacteria were present; 



2 Centralblatt f. Bacteriologie, Bd. xl. 



GENERAL ETIOLOGY OF EAR DISEASES. 45 

25 cases of meningitis secondary to otitis media occurred in the 
same series in which streptococci were found in 13, pneumococci in 
4, streptococcus mucosus in 1, pseudoinfluenza bacillus in 1, 
influenza bacillus 1, colon bacillus 1, tubercle bacillus 1. In the 
remaining cases the results were negative. 

Opinions differ as to whether the mere presence of pathogenic 
bacteria in the middle ear is sufficient to induce a purulent otitic 
inflammation unaided by some pre-existing pathological alteration 
in the mucous membrane. 

So far as our present knowledge goes it may be assumed that 
the effects of micro-organisms, in so far as they relate to various 
complications of middle-ear suppuration, are modified by the ana- 
tomical relations of the parts in which they find themselves, the 
resisting power of the patient, and probably to some extent by the 
nature of the pabulum in which they live. 

According to Libman, the dangerous and non-dangerous types 
of infection may be differentiated in the following manner: — 

1. Dangerous. — Purulent aural discharge containing diplococcus 
intracellulars, streptococcus pyogenes plus abundant leucocytes 
and myelocytes, also with epithelial elements, "acid-fast" squamae. 

2. Non-dangerous. — Staphylococci plus abundant living leuco- 
cytes. 

3. Giant Cells. — Tuberculosis. 

Finally, we believe that the information gained from bacterial 
examinations of the products of the middle-ear infection is of 
diagnostic value, and its value in the province of etiology, diagnosis 
and treatment will become augmented in proportion to the perfec- 
tion of our knowledge, not only of bacteriology, but of the infinitely 
more interesting and intricate problem of vaccine therapy, at the 
gateway of which we seem now to be. 

Traumatism. — Injuries of the middle ear and labyrinth occur 
from both direct and indirect violence. The external ear receives 
its injuries by direct means only. 

They occur in the form of (a) fractures of the temporal bone 
and fractures and dislocations of the ossicles; (b) wounds and con- 
tusions of the soft tissues ; (c) the impact of foreign bodies like 
bullets, splinters or knife-blades into both soft and bony tissues ; 
(d) burns, scalds and escharotics ; (e) concussion from explosions, 
loud noises, falls and blows. 

Fracture of the temporal bone (Fig. 35) assumes a variety of 
forms, several of which are attended with most serious conse- 
quences to the ear. A fracture of the petrous portion of the 
temporal bone, which involves the labyrinth usually gives rise to 
labyrinthine hemorrhage, vertigo, and, in some cases, destruction 
of the sound-perception function as a result of pressure and inflam- 
mation. 

If, by any means, a labyrinthine fracture communicates with a 
purulent ear, or otherwise becomes infected, a purulent labyrin- 
thitis becomes imminent, with a probable extension to the meninges 
and a fatal termination. 



46 



GENERAL CONSIDERATIONS. 



A fracture may extend from the squamous portion through the 
bony canal without injury either to the labyrinth or mastoid process. 
Likewise, it may rupture the membrana tympani and ossicular at- 
tachments, and thus open the middle ear. 

Compound fractures of the mastoid process are prone to result 
in purulent mastoiditis, with extension to the middle ear and some- 
times with meningeal complications. Any injury to the cranium, 
which is followed by hemorrhage from the external auditory canal, 
sudden deafness, vertigo or loss of consciousness, is of serious 
import. 

Labyrinthine concussion from explosions or violence, when 
unaccompanied by fracture or rupture of the soft tissues may result 




Fig. 35. — Fracture of the temporal bone through the labyrinth, a, Parietal 
surface, b, Visceral surface. 



in vertigo, vomiting, nystagmus and marked impairment of hearing 
for varying intervals of time. Concussion from "boxing the ear" 
is often of sufficient force to rupture the drum membrane. 

The prominent location of the auricle renders it particularly 
liable to wounds, contusions, abrasions and other injuries. Con- 
tusions of the auricle tend to produce hematomata, abscesses and 
perichondritis, the latter often resulting in extensive destruction of 
the cartilage and subsequent deformity. 

Stab wounds, bullet wounds, blows or falls produce an infinite 
variety of injuries both in location and extent, and involve the 
auricle, the external canal, or, by extending through the membrana 
tympani, the middle ear becomes exposed to infection from without. 

The brutal custom of pulling or twisting the ear as a means of 
punishment commonly results in traumatism along the postero- 
superior canal wall, and possible rupture or other injury to the 
drum membrane. 

Foreign bodies in the form of splinters, bullets or other pro- 
jectiles are prone to lodge in the deeper portions of the ear, 



GENERAL ETIOLOGY OF EAR DISEASES. 47 

viz., the auditory canal walls, tympanic cavity, labyrinth and mas- 
toid. Here they cause serious impairment or destruction of the 
auditory function, depending upon the location and extent of 
the injury and the attendant inflammation. Even the Eustachian 
tube is not exempt from occasional injury. In any form of trau- 
matism there is much to be feared from subsequent infection of the 
wound. 

Burns and scalds are usually accidental but none the less 
serious. Douching the ear with superheated solutions and the 
instillation of escharotics in the form of ear drops are the chief 
sources. Molten lead, hot oil, steam and similar substances pro- 
duce violent and deep-seated inflammation, with ulceration and 
destruction of the aural tissues, often terminating in serious impair- 
ment of the hearing function, partial or complete occlusion of the 
external meatus, and deformity of the auricle. 

Cold. — The influence of cold in milder forms, notably mild 
draughts, the introduction of cold water in the external auditory 
canal from washing or sea bathing, is overestimated by both prac- 
titioners and laity as a cause of aural inflammations. 

The sudden entrance of cold water in surf bathing or diving 
may give rise to a slight congestion along the meatus, or even a 
mild myringitis, but it never produces purulent inflammation of the 
middle ear except when a perforation of the drumhead already 
exists. Neither is it possible to induce middle-ear inflammation by 
exposure of the auricle to a draught of cold or damp air. Such an 
exposure in weakened or coddled individuals may induce a general 
cold from which an otitis may result, but under normal conditions 
this does not happen. The prevalence of aural infection following 
surf bathing, diving, etc., is not due to the cold or its effects, but 
invariably results from the more or less violent efforts to blow the 
surplus water from the nose and nasopharynx, whereby a portion 
of the existing infection is forced through the Eustachian tube into 
the tympanic cavity. 

Adenoids. — Postnasal adenoids constitute an obstructive lesion 
in the nasopharynx and as such interfere with nasal respiration. 
Furthermore, the irregular corrugated surface of the lymphoid mass 
favors the growth and retention of pathogenic organisms ; hence, they 
tend to interfere with normal tubal ventilation, and at the same 
time expose it to infection. 

Frostbite is usually confined to the more exposed parts of the 
auricle, and ordinarily produces circumscribed redness, swelling and 
dermatitis. When of unusual severity it is characterized by nodular 
formations, ulcerations and permanent dermatitis, with some gan- 
grenous sloughing of the auricle. 

General Diseases. — The aural complications of systemic diseases 
arc fully described in Chapters XXIX, XXX, XXXI and XXXII. 
These cover a wide range of causes, not only of purulent and 
catarrhal inflammations, but in some instances deleterious changes 
in the function of the auditory apparatus. 



48 GENERAL CONSIDERATIONS. 

Heredity and Environment. — The influence of heredity, either 
through congenital defects in the auditory apparatus, or predisposi- 
tion to catarrhal or labyrinthine deafness, is common. Deafness, 
unless congenital, usually commences in the different generations 
of a family at about the same age. It may skip one or two genera- 
tions, only to recur in like form. This is especially true of the 
sclerotic and labyrinthine types. Home surroundings, mode of life 
and atmospheric conditions are causes of several forms of aural 
disease. Individuals who are continuously subjected to filth of 
body and house, vitiated air. insufficient nourishment and clothing, 
show a tendency to dermatitis of the auricle and external meatus, 
tuberculous otitis and feeble resistance to any form of inflammatory 
invasion of the ear. 

Atmospheric conditions are deserving of mention. Vitiated 
air, especially when damp and cold, aggravates all forms of aural 
diseases, while serious results are experienced by those who are 
subjected to sudden rarefaction and condensation of the air within 
the auditory canal and tympanic cavity. Those who work in 
caissons, climb to high altitudes, or ascend in balloons, suffer 
from tinnitus, vertigo and deafness. In the caisson work connected 
with the numerous tunnels now being constructed in and about 
New York City, many cases of sudden labyrinthine deafness have 
occurred. 

Drugs and Narcotics. — The excessive use of certain drugs, 
especially quinine, the salicylates, opium, alcohol and tobacco, espe- 
cially when continued at great length, seriously interferes with the 
function of hearing, inducing aggravating tinnitus, with possible 
permanent loss of hearing. 

It will be observed that the causative agents herein defined may 
be grouped under three headings : — 

(a) Those which originate in the nose and nasopharynx and 
enter the tympanic cavity through the Eustachian tube. 

(b) Those which originate from without, in the form of trau- 
matism of the soft and bony tissues, concussion, lodgment of 
foreign bodies, burns, scalds, etc. 

(c) Those caused from heredity, environment and general 
systemic diseases. 

The Causes of Deafness. — Brief mention is here made of the 
causes of temporary, partial and permanent deafness. 

Hardness of hearing may result from, 1, diseases, obstructions 
and defects in the external auditory canal, among which are furun- 
culosis (Fig. 67), dermatitis, impacted cerumen (Fig. 69) and other 
foreign bodies (Figs. 70, 71), exostoses (Fig. 97), and congenital 
and acquired atresia. 

2. Diseases of the membrana tympani in the form of perfora- 
tions, sclerosis, myringitis, cicatrices and adhesions. 

3. Diseases of the tympanum confined chiefly to acute and 
chronic catarrhs, sclerosis, acute and chronic inflammations (puru- 
lent), adhesions, ankylosis of the ossicular chain, congenital defects, 
caries and otosclerosis. 



GENERAL ETIOLOGY OF EAR DISEASES. 49 

4. Labyrinthine disease the principal varieties of which are 
acute inflammation, purulent labyrinthinitis, hemorrhage, trauma- 
tism, necrosis, congenital defects,- neuroses, tuberculosis and 
syphilis. 

In conclusion, it -should be noted that the various etiological 
factors considered in this chapter furnish the basis for innumerable 
suits for damages for loss of hearing, wherein the otologist may be 
called upon for an expert opinion. 



CHAPTER VI. 
GENERAL SYMPTOMATOLOGY- OF EAR DISEASES. 



TOTAL DEAFNESS. 

(a) Idiopathic Total Deafness. — Total deafness sometimes 
occurs in the absence of all anatomical anomalies of the organ of 
hearing - , the auditory nerve or the acoustic centres. Under these 
circumstances explanation of this loss of function is difficult, 
inasmuch as most cases of congenital deafness are due to anomalies 
occurring in some portion of the auditory mechanism. The idio- 
pathic variety of congenital deafness does not* always follow directly 
from generation to generation. The offspring of deaf mutes usually 
possess the power of hearing, mutism being more common when 
both parents are congenitally deaf. The deafmutism is prone to 
recur from time to time in later generations. The children of con- 
sanguineous marriages furnish a considerable proportion of all 
forms of congenital deafness. 

Total idiopathic deafness occurs with extreme rarity, but suffi- 
cient data have been obtained by postmortem examinations to estab- 
lish sufficient proof of its occurrence. Mutism from this source is 
invariably permanent. 

Generally defective mental development seems to have no 
influence upon the function of hearing. As a rule those who suffer 
from loss of audition are found to be possessed of strong mentality. 

(b) Symptomatic Total Deafness. — By far the larger propor- 
tion of cases of total deafness, whether congenital or acquired, 
exhibit anomalies or pathological defects of the organ of hearing, 
the auditory nerve or the acoustic centres. In some instances 
evidences of intra-uterine diseases are observed, and histories of 
traumatism, sclerosis, purulent inflammation or senile degeneration 
are common. Anomalies of the organ of hearing furnish a con- 
siderable percentage of all cases of congenital total deafness. The 
congenital absence of certain portions of the conducting apparatus, 
often associated with deformity of the external ear, is by no means 
rare — a fact which has been repeatedly demonstrated by post- 
mortem findings. The external meatus may be partially or entirely 
absent (Fig. 75). but meatal atresia, in this type, should be differ- 
entiated from the acquired variety which does not usually occur in 
early life. The latter results from prolonged purulent inflammation 
of the middle ear, from exostoses or from traumatism. Any 
anomaly which permanently occludes the oval or round windows, 
or which destroys the functional activity of the auditory nerve may 
result in total deafness. Anomalies of that portion of the central 
nervous mechanism governing the acoustic centres occur either 
congenitally or as a result of disease or traumatism. Injuries to 
the head during childbirth, and rare instances of intra-uterine 

(50) 



GENERAL SYMPTOMATOLOGY OF EAR DISEASES. 51 

disease, such as fetal meningitis or infantile otitis, are occasionally 
etiological factors. 

The acquired variety includes a rather large series of cases 
resulting from epidemic cerebrospinal meningitis, traumatism and 
labyrinthine disease. Every epidemic of cerebrospinal meningitis 
results in a large increase in the proportion of cases of total deaf- 
ness observed both in hospital and private practice. 

Chronic catarrhal otitis media accompanied by extensive oto- 
sclerosis which walls off the labyrinth from the tympanic cavity, 
thus destroying its perceptive function, is a common cause of total 
deafness. 

To this series must be added those cases of total deafness 
developing in advanced life, explainable on the theory of senile 
degeneration. 

In both the idiopathic and the symptomatic varieties the pre- 
dominating symptom is the complete absence of all sound percep- 
tion, including the entire musical scale. 

The intracranial lesions of syphilis, whether acquired or he- 
reditary, are rarely of sufficient extent to produce total deafness. 
The author has observed but one case of this type. 



PARTIAL DEAFNESS. 

(a) Congenital. — The congenital form of partial deafness is 
due to some form of anomaly of the auditory mechanism. 

(b) Acquired Partial Deafness. — Partial deafness, developing 
after birth, is common, and is due to either intrinsic or extrinsic 
disease along the auditory tract, or to traumatism. It involves the 
sound-conducting apparatus, the labyrinth, the acoustic nucleus or 
the acoustic centres. 

Heredity exhibits some marked peculiarities, the onslaught of 
the disease occurring during the same decade in different genera- 
tions of one family, whether due to catarrhal inflammation, oto- 
sclerosis or labyrinthine disease. The latter variety is more com- 
monly associated with the hereditary tendency. 

Symptoms. — The symptoms of partial deafness vary from a 
slight diminution of normal sound perception to total loss of the 
hearing function. Hardness of hearing may be limited to certain 
sounds or groups of sounds, in which event great difficulty is experi- 
enced in differentiation, especiallv ordinary speech and musical 
tones, while often a slight noise, like the click of the acoumeter or 
the ticking of a clock, may be readily perceived. The extremely 
variable behavior of altered function toward rhythmical and non- 
rhythmical sound waves has been explained as due to some patho- 
logical condition located in the sound-conducting portion of the ear, 
or to an abnormal activitv of one of the roots of the auditory nerve. 
In the presence of rigid labyrinthine windows, speech and other 
noises are sometimes perceived only as a diffused noise. 

Senile deafness presents some definite characteristics, among 
which may be mentioned the gradual disappearance of sound per- 



52 GENERAL CONSIDERATIONS. 

ception, especially the conduction of sound through the bones. 
This is probably due to the altered power of bone conduction result- 
ing from senile processes in the bone tissue. According to Bezold, 
bone conduction in old age is diminished in direct proportion to the 
general decrease of hearing, the hearing decrease being considered 
due to senile torpidity of the auditory nerve. 

In the acquired forms of partial deafness certain tones are 
usually more distinctly heard, as a rule the higher pitched noises 
being the first to disappear. This depends somewhat upon the 
etiological factors, as well as to whether the deafness is due to 
defect of the conducting or of the receiving apparatus. Whenever 
partial deafness has been occasioned by an occupation which has 
confined the individual to very noisy quarters, the function of 
hearing differs from that occasioned by ordinary labyrinthine 
disease. In fact an almost infinite variety of hearing phenomena 
are observed. Occasionally the sound pitch is different in the two 
ears. Periodical variations in the degree of deafness are also of 
common occurrence. They may be of irregular duration, and often 
depend upon physical conditions, organic disease, or auditory nerve 
fatigue. Acquired deafness has a marked tendency to matitudinal 
exacerbations. Postprandial deafness deserves mention, especially 
when stimulants and tobacco have been indulged in too freely. 

The physiological decrease of hearing during the act of yawn- 
ing is probably explainable upon the theory of muscular inaction. 
Increase of the hearing is often induced by changes in bodily 
attitudes, such as stooping, bending of the head, or by alternation 
in muscular tension. 

Intermittent deafness is often a symptom of tubotympanic 
catarrh. This symptom is also exhibited in hysteria, epilepsy, and 
vasomotor affections. 

The periodical character of certain forms of partial deafness 
has been observed as accompanying malarial disease, cinchonism 
being included in this class. 

Peculiarities in the functional relationship of the right and left 
ear to each other are occasionally observed. 

It has long been known that in order to locate the origin of 
sound waves the function of both ears is simultaneously required, 
the direction being determined chiefly by a comparison of the 
sensation perceived in both. This function is so perfectly developed 
as to be well-nigh involuntary. Persons who are suddenly deprived 
of the hearing in one ear suffer great inconvenience in locating the 
direction of sound impulses. Politzer has termed this symptom 
paracusis loci. Victims of this phenomenon usually refer the sound 
to the more nearly normal ear, which may result in error of sound 
direction. 

Hyperesthesia Acoustica. — A series of phenomena, usually of 
nerve origin, occasionally give rise to peculiar and often distressing 
deviations from the normal hearing function. These have been 
described under various synonyms, according to the peculiarities 
found in the individual case. 



GENERAL SYMPTOMATOLOGY OF EAR DISEASES. 53 

Hyperesthesia acoustica is an apparent abnormal increase in 
the sense of hearing, especially for certain tones and sounds. There 
is usually no real increase in the hearing function; an actual diminu- 
tion may be present. The condition has been observed by Charcot 
to occur during certain phases of normal sleep and during hypnosis. 
It occasionally follows chloroform anesthesia, and may accompany 
the habitual use of morphine. Victims of hysteria, migraine and 
insomnia are frequently subject to it, in conjunction with a similar 
state of other special senses, and it may precede the evolution of 
deafness. Hyperesthesia of the sensory nerves is manifested in 
increased sensitiveness to sounds, causing painful or otherwise dis- 
agreeable reaction to loud noises or tones, especially those of high 
pitch. 

Temporary hyperesthesia acoustica often persists for some 
time after the removal of an old impediment to sound perception, 
such as a mass of cerumen from the external auditory canal. The 
author has observed it in one or two instances following the sudden 
restoration of hearing subsequent to use of the bougie in over- 
coming strictures of the Eustachian tube. 

In this class of cases the apparent hyperesthesia is the result 
of sudden restoration of normal hearing function. 

Paracusis is a term applied to a variety of perversions of the 
sense of hearing, the chief of which is 

Paracusis Willisii, in which the individual is deaf to speech 
uttered in silent surroundings, but, on the contrary, he is able to 
hear perfectly in the presence of loud, extraneous noises like those 
of underground railways, or the works of machine shops, etc. 
Occupation is a prominent causative factor, an illustration of the 
phenomenon being found in the so-called "boilermakers' deafness." 
It is supposed to result from compression of the labyrinth in the 
form of otopiesis. There is, however, no unanimous interpretation 
of this phenomenon, although attempts have been made to explain 
it on the basis of improved sound conduction through increased 
vibration verms increased sensitiveness to sound through stimula- 
tion of the auditory nerve by the more forcible accompanying sound 
waves. 

Diplacusis, or double hearing, may occur in two forms: first, 
the hyperesthetic, in which the phenomenon is due to abnormal 
stimulation of the organ of hearing (the perceptive mechanism), the 
manifestation of which is the acoustic continuation of sound impres- 
sions after the sound has really ceased. The second form of dipla- 
cusis results from the duplication of sounds upon the basis of 
delayed or weakened perception in one ear, and often is manifested 
by hearing a given tone higher in one ear than in the opposite. 
This. condition, known as diplacusiochotica, is usually observed in 
conjunction with middle-ear disease. 

Autophony, or tympanophony, is characterized by an abnormal 
increase of perception of one's own voice, respiration or circulatory 
impulses, in one or both ears, and is a condition which may accom- 
pany a closed as well as a permeable Eustachian tube. Occasion- 



54 GENERAL CONSIDERATIONS. 

ally it arises from a plugging of the external auditory meatus, 
and it may occur even with normal hearing. The nature of the 
phenomenon is obscure, but it has been explained as due to the 
increased resonance of the air column within the ear. Its occur- 
rence is occasionally dependent upon catarrhal inflammation of the 
nasopharynx. 

Acousma. — Auditory hallucinations are physical phenomena in 
which imaginary voices or sounds are detailed by the patients and 
persistently believed by them to be real. This symptom is some- 
times the earliest indication of perverted mentality. 

A case observed by the author was that of a woman of 35 
years, who resided within hearing distance of the trains running 
over a steam railway. She persisted in her belief that she could 
hear the ceaseless rumbling of a train, even when she was in the 
examination room. Other hallucinations gradually developed. 'We 
must reckon 1 with this symptom in making functional ear examina- 
tions. 

Vertigo. — The generally accepted theory of physicists that the 
semicircular canals with their ampullae are important factors in the 
control of the equilibrium of the body is explanatory of the fre- 
quency and significance of vertigo as a symptom in aural affections. 

Clinical experience is in harmony with this theory to the 
extent that labyrinthine pressure, oticodinia and irritation, whether 
extrinsic or intrinsic, may induce attacks of vertigo, of varying 
intensity and duration. 

When of intrinsic origin, the chief exciting causes are infection, 
anemia, hyperemia, meningitis, traumatism, gummata or granula- 
tions, usually with but sometimes without hemorrhagic, serous or 
pus exudate. 

In all forms of labyrinthine disease, vertigo is one of the most 
constant symptoms. Extrinsically, it is induced chiefly by the 
transmission of impulses, through the conducting apparatus or by 
the pressure of impacted cerumen upon the drum membrane or by 
intratympanic fluids, whether in the form of blood, serum or pus. 
It is further induced by gummata and other tumors and granula- 
tions, and by fixation of the stapes from hyperplasia or otosclerosis. 
The air douche during catheterization, and the water douche, either 
by pressure transmitted from the drum membrane, or directly to 
the oval window through large perforations, may give rise to 
vertigo, which subsides only upon the cessation of the exciting 
cause. Nausea may accompany the attack. Occasionally catheteri- 
zation has to be discontinued on this account. When induced by 
the water douche it is somewhat influenced by the temperature of 
the water employed, and when severe the douche temperature 
should he varied until little or no vertigo results. As a rule, there 
is less when the temperature is high; hence, it is well in all cases 
to commence with a temperature of at least 110°. 

Some patients, who on account of vertigo are unable to endure 
the douche in the upright posture, complain but little when it is 



GENERAL SYMPTOMATOLOGY OF EAR DISEASES. 55 

employed while reclining, and it seems to be somewhat less when 
the suction doucne (Fig, 46) is employed. 

In a small percentage of cases it is quite impossible to use the 
water douche under any circumstances, the vertigo being so severe 
as to result in alarming nausea, vomiting and even loss of con- 
sciousness. Here its use is obviously contraindicated. Vertigo is 
an occasional symptom in purulent otitis media, and also in both 
acute and chronic mastoiditis. In these affections it may appear as 
a result of pressure of pent-up pus upon the labyrinth ; nevertheless, 
it should invariably arouse suspicion of labyrinthine involvement, 
especially when accompanied by nystagmus. It is of a more serious 
import in chronic purulent otitic affections. 

Otitic vertigo may be rotary (the most common form) in which 
the sensation is that of whirling round and round toward either the 
right or left; or the tendency may be to fall directly forward, back- 
ward or in a lateral direction. 

The vertigo may be either objective, in which surrounding 
objects seem to move, or subjective, wherein the patient's body 
seems to be whirling or falling. 

More commonly it occurs in the upright posture, but whenever 
present in the recumbent posture it is invariably severe, continuous 
and persistent. Such patients commonly remark that the bed seems 
to be floating away, leaving them to sink lower and lower. In all 
cases etiological differentiation is important, inasmuch as otitic 
vertigo should not be confounded with the toxic, cerebral, ocular, 
gastric, hepatic or laryngeal types. The above symptoms are of 
importance in keeping case records. 

Meniere's Symptom-complex. — Meniere's symptom-complex, 
often designated Meniere's disease, is characterized by a marked 
sudden disturbance of hearing, invariably accompanied by three 
typical symptoms, viz., vertigo, tinnitus, nausea and vomiting. Of 
these the first named is the most pronounced. The attacks may be 
short or long, frequent or infrequent, and often terminate in an 
apoplectiform seizure minus loss of consciousness. In purely laby- 
rinthine cases the symptoms persist with exacerbations and remis- 
sions until deafness is total and the nerve destroyed. Locomotion 
is temporarily interfered with as a result of the accompanying 
vertigo, and persistent disturbance of hearing in one or both ears 
is usually present. One attack predisposes to another, and recur- 
rence is common, each attack subjecting the patient to the danger 
of further loss of hearing. Vertigo, nausea, tinnitus and sudden 
deafness sometimes result from labyrinthine traumatism. Here 
they are temporary, and should be differentiated from Meniere's 
disease, in which they result from a combination of pathological 
processes. It lias also been observed that tinnitus and deafness 
arising from middle-ear disease may accompany a simultaneous 
cerebellar affection, with its symptoms of vertigo, nausea and 
vomiting. An extension of pathological processes from the ear to 
the central nervous svstem, or vice versa, may also occur in cerebro- 
spinal meningitis, with resultant symptoms of vertigo, nausea and 



56 GENERAL CONSIDERATIONS. 

tinnitus. In the cerebrospinal meningitis of infants and young chil- 
dren there are additional differentiating symptoms of, first, fever 
and headache; second, a condition of stupor, developing during the 
course of the disease. 

Deafness resulting from cerebrospinal meningitis is common, 
and, when total, the hearing rarely returns. Partial deafness due to 
the same disease often improves spontaneously, or as a result of 
internal medication. The recovery of speech is aided by methodical 
hearing and speaking exercises. 

Deafness following Meniere's symptom-complex may be total 
or partial, or limited to certain sounds. 

The component symptoms manifest themselves at the same 
time, but it is quite possible for a single symptom to precede the 
general attack, or for the series to develop successively. In some 
instances an aura may precede the attack. 

The duration and frequency of the attacks are extremely 
variable. Etiologically, the evolution of these symptoms is due to 
primary disease or reflex excitation of the auditory nerve or the 
acoustic centres in the brain, the cerebral centres which determine 
the act of nausea and vomiting, and co-ordination. The symptoms 
are, as a rule, reflex, generally by way of the middle ear; more 
rarely, however, they result from disease of either the labyrinth or 
of the central nervous system. 

PAIN (OTALGIA). 

As a general symptom, referable to the ear or its surroundings, 
pain is usually due either to inflammatory conditions involving 
these parts, or to purely nervous or reflex manifestations. 

Inflammatory Pain, (a) Pain in the Pinna. — The prominence 
of the pinna (Fig. 61) and its exposed location render it extremely 
liable to traumatism, while, on account of its rather meagre nerve 
supply, the various injuries to which it is subjected do not, as a 
rule, evoke severe pain. Even injuries which involve the cartilage, 
examples of which are frequently observed in prizefighters and 
boxers and described in their vernacular as the "cauliflower ear" 
(Fig. 66), in which hematomata develop between the layers of 
cartilage, are not attended by severe pain. On the other hand, 
phlegmonous inflammations and herpes (Fig. 65) do give rise to 
considerable pain of a burning character. Under these conditions, 
whenever the swelling involves the anterior and more unyielding 
plane of the pinna, more pain is experienced than when the posterior 
aspect is involved, wherein the tissues are relatively looser and 
more yielding to the inflammatory infiltrate. Primary carcinoma of 
the auricle is attended with excruciating pain. 

(b) Pain in the External Auditory Meatus. — Traumatism in- 
volving the external meatus, on account of the resultant inflam- 
mation and infiltration, gives rise to severe pain, especially when 
the swelling is of sufficient severity to cause pressure. 

Pain becomes an early symptom of external otitis, and varies 



GENERAL SYMPTOMATOLOGY OF EAR DISEASES. 57 

in intensity with the severity of the inflammatory process. It is the 
chief symptom of the early stages of furunculosis of the external 
auditory canal, being aggravated by the introduction of instru- 
ments, or by attempts to move the pinna. When attended with 
swelling or edema of the parts, the painful condition becomes 
aggravated by acts of mastication, yawning, and even by speaking. 
The pressure of a foreign body and in rare instances impacted 
cerumen causes otodynia. 

(c) Pain in the Tympanic Membrane. — In simple inflamma- 
tions involving the membrana tympani, such as myringitis, slight 
pain may result, insufficient pressure being present to give rise to 
severe pain. Parasites deposited upon or penetrating the drum 
membrane have been known to cause severe pain. Traumatism, 
either direct or from concussions, causes pain, especially when 
sufficient to give rise to ecchymosis or rupture. An intense pain is 
produced during the act of injury to the drum. 

The tympanum is sensitive to touch or instrumental inter- 
ference, and following instrumentation pain may continue for some 
time. 

(d) Pain in the Tympanic Cavity, the Eustachian Tube, the 
Head and the Neck. — Simple inflammations involving the tympanic 
cavity and its accessories are usually characterized by the presence 
of pain, the exception being tuberculous or syphilitic involvement. 
On the other hand, the more severe purulent inflammations are 
attended by severe, lancinating and almost unbearable pain, which 
is usually definitely located within the confines of the middle ear. 
Patients are prone to indicate the location by pointing the index 
finger directly toward the external meatus. Some radiation of the 
pain is occasionally manifest. 

Caries involving the tympanic walls or adjacent bony struc- 
tures is sometimes characterized by pain which is of deep-seated, 
boring and stinging nature, often extending from the ear in various 
directions, and occasionally being noted even upon the opposite 
side. 

When intracranial or sinus involvement is present, the pain is 
referred to the head rather than to the ear, and may be diffused 
over the entire skull, or localized in the forehead, the middle cerebral 
region, or the occiput, and it manifests a tendency to nocturnal 
exacerbations. Otitic meningitis and brain abscess are character- 
ized by severe pain during certain stages. 

When the cartilaginous portion of the Eustachian tube is the 
seat of inflammation, the attendant pain manifests a tendency to 
radiate, especially downward along the neck, and is increased by 
the act of swallowing or by attempts to remove intranasal secretion 
by blowing. 

Retained purulent exudate induces the most severe of all 
types of pain. Pain along the neck, radiating from the ear, is often 
reflex, the causal factor being swollen and inflamed tonsils, ton- 
sillar abscess, or parotitis. 

(e) Pain in the Mastoid Process. — Both external and internal 



58 GENERAL CONSIDERATIONS. 

inflammatory processes involving the mastoid process are attended 
by varying degrees of pain. In traumatism and periostitis the pain 
is considerable, and is always increased by pressure or manipula- 
tion of the parts. It is an important symptom of mastoiditis, which 
is rarely absent, and is invariably aggravated by pressure, especially 
over the mastoid antrum and tip. The severity of the pain is not 
necessarily in direct ratio to the degree or extent of the mastoid 
involvement, and it is sometimes complained of even in the absence 
of any demonstrable inflammation involving these parts. In eburni- 
zation of the mastoid process, pain of a sharp'intermittent character 
is often noted, even after all active processes in the mastoid have 
ceased. 

Acute empyema of the mastoid cells generally gives rise to 
violent pain. 

After mastoid operations, in certain cases, the patients com- 
plain of pain in the mastoid region. This may either be of a 
neuralgic type, or from the involvement of nerve filaments in the 
resultant scar. 

Painful sensations are commonly felt about the mastoid proc- 
ess, coincidental to atmospheric changes. This type of pain is 
persistent and has no pathological significance. 

Pain, on deep pressure over the region of the internal jugular 
vein, is an indication of sinus-thrombosis, other symptoms coin- 
ciding. 

Sensations akin to pain, but usually described as fullness and 
pressure within the ear, are often observed in acute catarrh of the 
Eustachian tube, and in connection with the entrance of mucus 
into the tympanic cavity, during the act of violent blowing of the 
nose ; or from the penetration of fluid from the nasal douche under 
similar conditions. In some individuals pain follows the entrance 
of air into the tympanum as a result of politzerization or cath- 
eterization. 

(/) Neuralgic Pain. — Otodynia of neurotic origin may be re- 
ferred to almost any portion of the auditor}' apparatus, the most 
common location being within the tympanic cavity. This form of 
pain is commonly associated with hysteria and other functional 
neurotic disturbances. Sensory branches of the trigeminus and 
glossopharyngeal nerves may be involved, either as a result of 
intrinsic disease or through a transmitted reflex. 

Ramsey Hunt ascribes otalgias of the neuralgic type to affec- 
tions of the sensory system of the seventh nerve (nerve of Wris- 
berg, the geniculate ganglion and the petrosal nerves), claiming 
that otalgia bears the same relation to the facial nerve as does 
prosopalgia to the trifacial, and that in the facial nerve is to be 
found a sensory and reflex factor, of great importance in the inner- 
vation of the auditory mechanism.- He further defines an idio- 
pathic form of otalgia, reflex otalgia, double reflex otalgia, second- 
ary (herpetic) otalgia, tabetic otalgia and reflex aural neurosis. 

Dental caries or affections of the tonsillar or peritonsillar 
region are the most potent causes of otitic neuralgia. The pain 



GENERAL SYMPTOMATOLOGY OF EAR DISEASES. 59 

may be continuous or periodical, with remissions and exacerba- 
tions. There is usually a marked tendency to radiation toward the 
neck and shoulder. Neuralgic attacks located in the auditory canal 
may follow the entrance of cold water or air into the meatus. 
These are sometimes associated with generalized trigeminal 
neuralgia. 

Aural Discharge, (a) From the Walls of the External Canal. 
— Various diseases and injuries involving the external meatus are 
attended by discharge, either of mucus, serum, blood or pus. 

Herpes, lupus, circumscribed and diffuse otitis externa, otomy- 
cosis, foreign bodies, and certain forms of eczema, are often attended 
by discharges of mucus or serum, which is sometimes streaked with 
blood. 

Hemorrhage from the canal walls is uncommon and occurs in 
connection with traumatism, otitis externa hsemorrhagica, vicarious 
aural hemorrhage, and from the ulcerations of malignant growths. 

Pus discharge arises chiefly from the rupture of furuncles 
in the meatus, or from fistulous openings caused by burrowing 
abscesses in the parotid or lymph glands, or from the mastoid 
process. 

(b) From the Tympanic Cavity. — The chief source of aural 
discharge is found in the various diseases and injuries which involve 
the tympanic cavity, the otorrhea consisting of mucus, serum, 
blood and pus. The mode of exit is either through the Eustachian 
tube to the pharynx, or through the external auditory canal, as a 
result of rupture or paracentesis of the membrana tympani. 

Violent inflammation of ■ the t}mipanic cavity occasionally 
induces blood extravasations into the walls of the drum membrane 
in the form of blebs. 

Traumatism of the drum, both direct and from concussion, is 
usually attended by hemorrhage. 

Hemorrhage from the vessels of the tympanic cavity or its 
adjacent structures, vascular neoplasms, aural polypi, intratympanic 
granulation tissue, or from the middle ear in general, is of compara- 
tive frequency. Another source of aural hemorrhage is observed 
in fractures at the base of the skull, especially when involving the 
petrous portion of the temporal bone. Extensive fractures 
through tlie labyrinth sometimes permit the escape of cerebrospinal 
fluid from the external meatus. 

Intratympanic serous exudates are usually either absorbed or 
escape through the Eustachian tube, except when perforations 
already exist or rupture results from pressure. Otopyorrhea is an 
important symptom of acute and chronic purulent otitis media, 
with their various complications. The bacteriological characteris- 
tics of pus are described in Chapter V. 

Ear discharge, besides the above characteristics, is odorous, 
or non-odorous. 

Mucous, seropurulent, or hemorrhagic discharge usually is non- 
odorous. Purulency, unless of very short duration, is usually 
malodorous. 



60 GENERAL CONSIDERATIONS. 

The fetid discharges seen so often in the longer standing 
otorrheas is due to the chemical degenerations of the bony elements. 
It is almost pathognomonic of bone necrosis. 

Temperature. — Fever is a common symptom of phlegmonous 
inflammatory processes involving either the external or middle ear. 
Foreign bodies, whether in the external meatus or embedded in the 
deeper tissues, may indirectly produce fever as the result of attend- 
ant inflammation. Acute inflammation involving the tympanic 
cavity, whether catarrhal or purulent, is attended by more or less 
fever, especially in young children. 

The temperature of such inflammation, however, is variable, 
and its absence is sometimes noted. Retention of pus in the tym- 
panic cavity usually results in sufficient absorption to produce 
elevation of temperature. 

Temperature variations in acute aural affections are rarely 
pathognomonic, even when serious complications develop, with the 
exception of infection of the venous sinuses. Higher temperatures 
invariably prevail in the aural affections of infants and young chil- 
dren than in adults, but a high temperature, unattended by other 
aural symptoms, should never be considered sufficient ground for 
diagnosis of aural disease, and under these circumstances, until all 
the other possible causal factors have been eliminated, no operative 
interference should be attempted. 

High temperature, alternating with chills, associated with 
either acute or chronic purulent otitis media, indicates a pyemic or 
metastatic process, and should always direct the attention of the 
observer to involvement of the venous sinuses. 

Fluctuations in temperature, such as are sometimes present 
in purulent otitis, are characteristic of septic processes in general 
with a tendency to persist until the pus flow ceases. 

Ear Cough. — A peculiar spasmodic cough of reflex origin is 
often produced by the introduction of aural specula and other 
instruments into the external auditory canal, and it usually persists 
for a few seconds subsequent to the removal of the instruments. 
A similar cough is occasionally induced by the pressure of impacted 
cerumen, foreign bodies and swellings, in which it is persistent and 
alarming, on account of the suspicion which is aroused that some 
serious pulmonary or cardiac disease is present. 



CHAPTER VII. 

GENERAL DIAGNOSIS OF EAR DISEASES. 

Only diagnostic points of general significance are discussed in 
this chapter. The diagnosis of each aural affection will be fully- 
described in the chapters on these diseases. 

In examining the external ear it is important to note its size, 
its position, the surroundings of its insertion, the configuration of 
the concha, the orifice of the external auditory canal, the lumen of 
the canal, and the condition of its integument (Fig. 61). 

Otoscopic examination, the technique of which is fully de- 
scribed and illustrated in Chapter II, includes a minute inspection 
of the external auditory canal, the membrana tympani, the malleus, 
and any portion of the tympanic cavity which may be visible 
through a perforation of the membrana tympani, in the given case. 

Familiarity with the anatomical topography of the region 
examined, and the normal appearances, is a necessary adjunct to 
correct otoscopic diagnosis. A brief anatomical resume is therefore 
given here. 

The external auditory canal is composed of a cartilaginous and 
an osseous portion, joining at an obtuse angle, the outer or carti- 
laginous portion being the longer, measuring about 21 mm. in 
length, and the inner or osseous portion averaging about 14 mm. 
in length. 

Obviously the osseous portion admits of neither mobility nor 
dilatation; the cartilaginous portion, however, being a part of the 
auricle proper, admits of considerable motion in all directions, and 
dilatation is attainable to a slight degree. The auricle must be so 
manipulated as to render the meatus as straight as possible in order 
successfully to inspect the deeper portion of the canal and of the 
membrana tympani (Fig. 10). 

There are various developmental stages of the external audi- 
tory meatus, and, also, individual peculiarities, both as to size and 
direction. In infants under one year of age the walls of the audi- 
tory meatus are more readily separated by pulling the concha 
outward and downward. In adult life the auditory meatus is 
brought more nearly to a direct line by pulling the concha in a 
backward, outward and upward direction. It is sometimes possible 
in adults to obtain a satisfactory view of the entire auditory meatus 
and even the membrana tympani, without the insertion of a specu- 
lum. Individual peculiarities often necessitate changes in the 
direction of traction in order to compensate for curvatures in the 
cartilaginous portion or abnormal direction in the osseous canal. 
In children the entire external meatus is practically straight and 
little or no traction is necessary. In infants, as a result of the 

(61) 



62 GENERAL CONSIDERATIONS. 

absence of the osseous portion, the superior and inferior canal walls 
are usually in contact. 

The Membrana Tympani. — The inner extremity or fundus of 
the external auditory meatus is made up of the membrana tympani, 
which assumes an oblique position, being so located that its postero- 
superior attachment is nearest to the external world (Fig. 103). 

In examining the drum membrane its relative position, form, 
color, inclination, curvature, thickness, and light reflex are to be 
determined. 

In contour the normal drum membrane is a somewhat pear- 
shaped oval (Fig. 101). The diameter is from 8 to 10 mm. It is 
sufficiently indrawn toward the umbo to render it concave, the 
concavity being somewhat relieved by the position of the short 
process of the malleus. The irregularity of its surface and the 
impress of the malleus from behind enable one to locate certain 
typical landmarks. Of these the color of the membrane, the 
presence of the short and the long processes of the malleus, the 
position of the anterior and the posterior folds, the umbo, and the 
light reflex are the chief landmarks. 

The most prominent landmark, and the one usually first sought 
for, is the short process (Fig. 102). It is located near the upper 
periphery, at the junction of the anterior and posterior folds, pro- 
jecting into the lumen of the external auditory canal, under cover 
of the drum membrane, in the shape of a minute yellowish-white 
button. The long process (Fig. 102) extends downward and back- 
ward from the short process, terminating in the lower half of the 
tympanic membrane in the form of a small disk, which is termed 
the umbo. At the umbo the apex of the light reflex will be 
observed (Fig. 102), gradually broadening and entending toward 
the anterior inferior periphery, the cone normally assuming the 
shape of an equilateral triangle. Variations in the lustre of the 
drum membrane are of marked diagnostic significance. Disap- 
pearance of or any alteration in the light reflex (Fig. 101) is an 
indication of pathological changes in the drum membrane. 

The anterior and posterior folds extend from the short process, 
the anterior forward and slightly upward, and the posterior back- 
ward and slightly upward, serving as the dividing line between 
the membrana flaccida and the membrana tensa (Fig. 102). 

The color of the normal drum membrane, as seen in the living 
subject, is pearl}'- white, but is admissible of rather wide variations, 
dependent upon the source of illumination and the condition of the 
tympanic cavity. The color also varies with age, from a milky 
white in the child, due to preponderance of epidermal structures, to 
a neutral gray, mixed with a faint tinge of violet or light brownish 
yellow, in the adult. In old age it returns to the whitish color. 

In labyrinthine and auditory nerve deafness, when uncom- 
plicated by middle-ear disease, the membrana tympani may be 
normal in position and appearance. 

Obstacles to Otoscopic Diagnosis. — An otoscopic examination 
in a large meatus containing no debris, exostoses, deformities or 



GENERAL DIAGNOSIS OF EAR DISEASES. 



63 



swellings is not a difficult procedure. Epithelial debris or masses 
of cerumen lying upon the walls of the external auditory meatus 
are liable to impinge upon the distal end of the speculum and 
obstruct the view. Another common obstruction is found in bulg- 
ing of any portion of the external meatal wall into its lumen, denot- 
ing infiltration, exostosis, or abscess (Fig. 68) of the canal. Exos- 
toses always arise from the osseous canal wall and are hard to the 
touch of the probe (Fig. 97). Abnormally small and tortuous 
canals are sometimes encountered, requiring the use of specially 
long specula of small calibre in order to inspect the deeper por- 
tions. The pressure of the aural speculum sometimes induces 
reflex cough, the avoidance of which is rendered possible by careful 
and gentle manipulation. 





Fig. 36. — Lateral view of the tympanic cavity and drum membrane, 
with key plate. The illustration shows (1, 2) marked retraction of both 
the inferior and superior quadrants of the drum membrane and (3) marked 
prominence of the short process. 



Pathological Changes in the Membrana Tympani. — Certain 
pathological changes in the drum membrane produce alterations in 
its appearance which are closely related to the general diagnosis of 
ear affections. 

(a) Hyperemia. — The hyperemic drum is characterized by a 
local distention of the blood-vessels (Fig. 106), those about the 
manubrium and around the periphery being usually involved. 
When hyperemic, the numerous anastomoses about the periphery 
give to the membrane the appearance of being surrounded by a red 
ring which extends outward into the canal, often obliterating the 
tympanic boundaries. In severe hyperemia the entire membrane 
presents a bright-red appearance. A typical hyperemia is often 
observed after vigorous douching for the removal of impacted 
cerumen, or from accidentally touching it with probe or cotton 
carrier. 

(b) Ecchymosis. — Extravasations of blood between the layers 
of the tympanic membrane usually occur in the form of dark-red 
dots or streaks, and these cannot always be differentiated from 
hemorrhages of the mucosa (Fig. 122). 

(c) Anomalies of Curvature. — (Increasing concavity, convex- 



6 4 GENERAL CONSIDERATIONS. 

ity, retraction, abnormal thickening). In partial convexity of the 
tympanic membrane, circumscribed portions appear sunken or re- 
tracted and somewhat funnel-shaped (Fig. 36). Marked retraction 
of the anterior segment alone is often partially masked by the 
anterior surface of the malleus handle. Marked retraction of the 
entire tympanic membrane with the handle of the malleus bound 
down by adhesions (Fig. 37) gives an appearance which is some- 
times mistaken for destruction of the drum membrane, with derma- 
tization of the tympanic cavity. Variations in the position of the 
malleus handle cause considerable variety of abnormal reflections 
and curvatures to the drum membrane. Retraction of the drum 
membrane gives undue prominence to the manubrium. The appar- 
ent prominence is sometimes noticeable even when the manubrium 
is indrawn and foreshortened. Retraction of a normal or atrophic 
drum brings to view various intratympanic structures, notably the 




Fig. 37. — Marked retraction of the drum membrane, showing contact of 
the foreshortened manubrium with the promontory. 

long process of the incus, the incudostapedial joint, and the promon- 
tory. Retraction always gives prominence to the short process of 
the malleus, and when the manubrium is simultaneously fore- 
shortened the projection of the short process pulls the anterior and 
posterior folds into plain view (Fig. 38). Inflammatory thickening 
of the drum membrane alters or obliterates the normal landmarks. 
Commencing with the alteration in color, the light reflex, umbo, 
manubrium, and sometimes the short process become lost to view 
in the inflammatory exudate. 

(d) Solution of continuity of one or more layers of the mem- 
brana tympani (rupture) : Convexity or displacement of the mem- 
brane outward is commonly termed bulging. When convexity or 
bulging involves a single tympanic segment, whether anterior or 
posterior, the remaining segment has the appearance of marked 
concavity. When the entire tympanic membrane becomes convex 
the influence of the manubrium in holding that portion of the mem- 
brane covering it in place causes it to lie apparently in a furrow 
of the membrane. Bulging involving the posterosuperior segment 
changes the entire appearance of the tympanic portion of the canal, 
obliterating its oval proportions and narrowing its diameter from 
above downward, and partially obscuring the anterior segment 



GENERAL DIAGNOSIS OF EAR DISEASES. 



65 



(Fig. 126). This condition, when accompanied by violent inflam- 
mation and stasis, is sometimes mistaken for granulations. 

Sudden acute inflammation involving the tympanic membrane 
occasionally gives rise to the formation of blebs or extravasations 
into the membrane, which eventually break down and rupture 
either outward or inward, with or without the formation of a 
complete perforation (Fig. 122). 

(<?) Perforations and Cicatrization. — Perforations of the tym- 
panic membrane are variable both in size and location. The dis- 
covery of perforations is never difficult to the experienced, but to 
the casual observer they often escape notice. Large perforations 
with well-defined borders, where no granulations or adhesions exist, 
are easily demonstrable (Fig. 39). When the whole drum is absent 
the fundus of the canal appears more distant from the eye and 





Fig. 38. — Lateral view of the tympanic cavity, drum membrane and 
bony meatus, with key plate. The illustration shows (1) marked retrac- 
tion of the membrana tympani ; (2) foreshortening of the long process of 
the malleus; (3) prominence of the posterior fold; (4) undue promi- 
nence of the short process. 



the outlines of the intratympanic structures become visible. Old 
perforations, especially when they have become healed or are 
bound down at the edges by adhesions, can only be seen upon close 
inspection. Small perforations in the membrana flaccida above the 
short process are generally overlooked, unless the examiner ha- 
bitually observes the entire peripheral attachment of the drum. If 
doubtful as to whether perf orations exist the Siegel otoscope (Fig.' 
26) should be employed, and the membrane carefully observed 
when suction is made. This serves the double purpose of deter- 
mining whether the drum membrane is adherent to the promontory 
or lateral tympanic walls, and the presence of perforations. If no 
movement is apparent, and no perforation borders come into view 
during suction, it may be assumed that the drum is wholly or 
partially absent. In chronic purulent cases with continuous dis- 
charge, granulations are usually present and are prone to fill and 
obscure the perforation aperture. Tn the acute stage the accom- 
panying inflammation gives rise to marked reddening and swelling. 
Perforations resulting from traumatism are at first linear but 



56 GENERAL CONSIDERATIONS. 

become oval after a time, and with less reddening and swelling of 
the parts. Close observation of the margins of perforations reveals 
the fact that they are almost invariably red. 

Perforations usually occur singly, but multiple perforations in 
the same drum membrane ( Fig. 175) are occasionally observed, 
especially in cases of tuberculous and syphilitic origin. 

Perforations may remain unhealed long after the cessation of 
the purulent discharge. Nature's method seems to vary as to the 
process of healing. Commonly over a large perforation will appear 
a thin film of new formation, while at the same time the margins 
remain clearly outlined even though thickened and sclerosed. The 
atrophic appearance and transparent quality of the new formation 
is explained by the absence of the substantia propria in the scar 
tissue. Upon inspection the scar presents a darker appearance than 
normal, and the various parts of the tympanic cavity may be seen 




Fig. 39. — Large perforation of the membrana tympani. The malleus 
handle is attached to the promontory by adhesions. The illustration also 
shows outline of round window. 

with more or less distinctness. The scar tissue may be so delicate 
as to give the impression that nothing intervenes between the eye 
and the tympanic cavity, and is, therefore, often mistaken for the 
perforation. At times the perforation scar has an unusually glisten- 
ing surface. The margins of the scar are generally sharply differ- 
entiated from the rest of the tympanic membrane, but occasionally 
they merge into it gradually. In other instances the closing of the 
perforations is accomplished by a variety of cicatrices, the most 
common form being those in which the margins of the perforation 
become attached and held firmly to the walls of the tympanic cavity 
by cicatricial bands. Continued purulent exudate, with large per- 
forations of the tympanic membrane, may finally become localized, 
leaving the remaining portion of the membrane comparatively 
normal. In other cases the destruction may be so extensive as to 
involve the entire drum, together with portions of the tympanic 
walls, leaving the surfaces rough and uneven in appearance, often 
complicated by the development of extensive sclerosis, with almost 
complete obliteration of the normal anatomical outlines. Occa- 
sionally scattered red spots devoid of epidermis, or yellowish disks 
due to a colloid deposit, or calcareous plaques appear in the 
sclerosed tissue (Fig. 114). 



GENERAL DIAGNOSIS OF EAR DISEASES. 67 

Circumscribed atrophy involving portions of the tympanic 
membrane is recognized by a somewhat darker coloration and an 
apparent umbilication. In extensive atrophy involving the greater 
portion of the membrane it presents an almost transparent appear- 
ance. Very frequently the irregular reflected light gives it the 
appearance of a piece of crumpled tissue paper (Schwartze). True 
atrophy of the tympanic membrane is differentiated from cicatriza- 
tion by its general character and indistinct boundaries as compared 
with the sharper outlines of a scar margin. As a rule the study of 
the tympanic picture enables one to clearly differentiate between 
these conditions. 

The Tympanic Cavity. — Certain portions of the tympanic 
cavity are visible when large perforations are present. Exposed 
ossicles, the promontory, the oval and round windows, and the 
pyramid are the parts commonly seen. Entire absence of the drum 
membrane and ossicles exposes the tympanic orifice of the Eusta- 
chian tube and a small portion of the epitympanic space. Small 
mirrors have been devised for inspecting other portions of the. 
tympanic cavity, but they have proven of no practical benefit. The 
small curved silver probe of Hartman (Fig. 3), carefully and 
delicately manipulated, enables the observer to determine granula- 
tions, carious or necrotic tissue in this region by the sense of touch. 

The Mastoid Process. — Inspection of the mastoid process is 
usually limited to its external covering. Limited opportunities for 
inspecting the internal portions are made possible only through 
large fistulous openings. Hyperemia and swelling of the external 
coverings of the mastoid process when present are not difficult 
of demonstration. In mastoiditis with postauricular swelling and 
occasionally as a result of enormous furuncles involving the pos- 
terior wall, the concha assumes a position almost at right angles 
to the head, indicating extensive periosteal involvement. Post- 
auricular swellings in the very young are almost invariably the 
result of purulent mastoiditis. In the adult they may be indicative 
of sinus involvement, especially when the surrounding tissues are 
edematous ( Kopetzky ) . 

The Eustachian Tube. — The only visible portion of the Eusta- 
chian tube is its pharyngeal orifice. In rare instances obstruction 
in the pharyngeal orifice may be demonstrated by ocular inspection 
by means of the pharyngeal mirror. The diagnosis of Eustachian 
obstruction and stenosis is determined only by means of the bougie 
(Fig. 25). It occasionally becomes possible to use the bougie 
through large membranous perforations, entering the tube through 
the auditory meatus. The method employed for this purpose 
requires a slightly twisting motion given to the probe. 

Auscultation. — Middle-ear auscultation possesses considerable 
value, especially in determining the condition of the Eustachian 
tube, and it is accomplished by means of a combination of ordinary 
catheterization in combination with the diagnostic tube, properly 
termed the otoscope (Fig. 21). Auscultation is of doubtful relia- 
bility for determining conditions prevailing in the tympanic cavity. 



68. GENERAL CONSIDERATIONS. 

Under normal conditions an air current blown through the catheter 
and Eustachian tube into the tympanic cavity transmits a rather 
low-pitched, soft, smooth, unbroken bruit, free from roughness, 
bubbling or whistling. Stenosis of the tube, whether partial or 
complete, communicates a high-pitched, irregular, sharp bruit, 
sometimes becoming almost a whistle. After dilatation, whether 
by means of continuous pressure of air or by means of the bougie, 
the air again rushes into the tympanic cavity with a full, smooth 
sound. The character of the sound may be considerably affected 
by the condition of the tympanic membrane. A tense membrane 
gives a sharper tone, whereas the tone is much softened by a 
yielding membrane. When membranous perforations exist the 
air current produces a plainly audible whistling bruit as it passes 
through the gap in the auditory canal. Perforation whistles are 
heard for a considerable distance from the patient. Whenever 
there is pus or other secretion in the Eustachian tube the current 
of air produces a bubbling or rattling sound. Absence of such 
rattling sounds may not always be taken as conclusive proof 
that the Eustachian tube and tympanic cavity are free from 
secretion, inasmuch as it has been shown that rather smooth 
sounds may be heard even when the outer portion of the tube 
and tympanic cavity are more or less filled with tenacious secre- 
tion. Explosive sounds are produced by inflammation when the 
tubal walls are collapsed. The same character of bruit is trans- 
mitted when the tympanic membrane is partially or wholly in con- 
tact with the internal tympanic wall. The tympanic membrane 
has been known to rupture as a result of the impact of the air cur- 
rent applied with undue force, in which instance a loud explosive 
sound would be transmitted. 

Absence of auscultatory bruit results from incorrect position 
of the catheter or of the aural tips of the diagnostic tube. It also 
results from various forms of tubal obstruction, such as extensive 
adhesions of the tubal walls, foreign bodies in the tubal canal, or 
possibly complete clogging of the tympanic cavity with masses of 
exudates. 

Whenever inflation is induced by the Valsalva method certain 
auscultatory sounds may be heard which do not originate from the 
tube or middle ear but are transmitted from the nasopharynx. 

Both ears should invariably be inspected at the preliminary 
examination of the patient, even though but one is complained of. 
For years the author has made use of the expression "Always 
examine the other ear" in his lectures to students. Even though 
the opposite ear is normal, its inspection is helpful by way of com- 
parison. In a large proportion of cases of chronic affections both 
ears are involved. Retained cerumen is bilateral as a rule, but the 
patient may complain only of the ear in which it has become 
impacted. A patient's declaration that he has never suffered from 
abscess of the middle ear is not always reliable, inasmuch as such 
statements are often disproved by the presence of old perfora- 
tion cicatrices in the drum membrane. 



GENERAL DIAGNOSIS OF EAR DISEASES. 69 

Lumbar Puncture. — From the standpoint of the otologist and 
the rhinologist lumbar puncture possesses both a diagnostic and 
therapeutic value. 

Diagnostic Value. — Since Corning 1 published his monograph 
upon lumbar puncture, the procedure has become widely known. 
Quincke introduced it into the realm of diagnosis in 1891-1892. From 
that time until the present day over 150 monographs and reports 
upon this subject have appeared in medical literature. Kopetzky 2 
has classified the essential points in the technique of the examination 
of the cerebrospinal fluid and outlined the diagnostic and therapeu- 
tic value of the procedure, and his classification, comments and 
references are as follows : — 

In the examination of the cerebrospinal fluid the following 
points are to be noted : (1) The pressure under which it is obtained. 
(2) Its coloration (chromodiagnosis). (3) The bacteriological 
findings. (4) Cytodiagnosis. (5) The chemical examination. (6) 
Cryoscopy of the fluid. 

Pressure. — The spurt of the fluid and the height of its curve 
while being withdrawn gives a fairly accurate idea of the degree of 
pressure, depending, however, upon the position assumed by the 
patient, the cardiac pulsation and respiratory activity. Quincke has 
observed a rise of pressure in persons with grave inflammatory condi- 
tions like tuberculous meningitis and tumors of the brain, the highest 
records resulting in tuberculous meningitis and acute hydroceph- 
alus. Slow exit of the fluid is an indication of hypotonia. Heiman 
advocates the employment of a manometer for estimating the degree 
of pressure. 

Color. — Normally the cerebrospinal fluid is clear and trans- 
parent. The pathological or accidental mixture with blood or 
micro-organisms produces a decided change. The presence of 
leucocytes is prone to give rise to a characteristic turbid appear- 
ance. The variations in color are usually from the normal clear 
transparent fluid to a cloudy yellow. In acute bacterial meningitis 
a well-defined purulent appearance is given. 

The fluid is prone to be clear in chronic meningitis, and usually 
is the same in the tuberculous variety. 

Bacteriological Findings. — Extensive investigations have been 
made in regard to the various micro-organisms which have been 
found. Of these nearly all forms have been differentiated, some- 
times occurring as mixed infections while others are monobacterial. 
Diplococci are common in meningeal inflammations. Weichsel- 
baum's diplococcus intracellularis is now the accepted exciting 
cause of cerebrospinal meningitis, and when found in the cere- 
brospinal fluid establishes a diagnosis. 

The bacteriological tests may be by direct examination or by 
cultures and animal inoculations, the latter, however, usually requir- 
ing too long a period of time when the dangerous character of the 
affection is taken into consideration. 



1 New York Medical Journal, 1885. 

2 Surgery of the Ear, p. 309. 



70 GENERAL CONSIDERATIONS. 

Among the pathogenic organisms which have been isolated 
from the cerebrospinal fluid are : the staphylococcus, streptococcus, 
Fraenkel's and Weichselbaum's pneumococcus, the Ebert bacillus, 
the colon bacillus, the tubercle bacillus. The tubercle bacillus is 
demonstrated only with considerable difficulty. Kroenig attributes 
the failure to an imperfect centrifugation or poor stain, thus 
emphasizing his belief in the possibility of demonstrating tubercle 
bacilli in all cases of tuberculous meningitis. A negative result 
may not necessarily prove the absence of pathogenic bacteria in the 
fluid for the principal reason that in such cases the medullary canal 
has not shared in the inflammatory process. 

Cytodiagnosis. — This term is employed to describe the histo- 
logical investigation of the cellular elements contained in the cere- 
brospinal fluid. 

Lymphocytosis of the cerebrospinal fluid is believed to indicate 
the presence of meningeal irritation, which may or may not be 
purulent meningitis. Lymphocytosis is especially marked in chronic 
meningeal affections (tabes, multiple sclerosis, syphilis and tuber- 
culous meningitis). 

Polynucleosis indicates acute meningeal irritation — for instance, 
meningitis of pneumococcus, staphylococcus or meningococcus 
origin. In this form the cerebrospinal fluid contains polymiclear 
leucocytes in sufficient quantity to produce a cloudy appearance. 
These tend to decrease as recovery takes place, being replaced 
by lymphocytes, which disappear after recovery. These observa- 
tions are confirmed by Labbe and Castaignes, Sicard and Bricy. 
Leutert has. observed marked general leucocytosis in meningitis of 
otitic origin. 

The examination of the cerebrospinal fluid, while important, 
is chiefly valuable when considered in conjunction with the clinical 
evidences in the individual case. 

Significance of Pathological Findings. — According to Chavasse 
and Mahu, 3 a clear, normal non-coagulable fluid indicates sinus- 
thrombosis, brain abscess (epi- or sub-dural), simple serous menin- 
gitis, meningismus, hysteria, and occasionally a circumscribed 
meningitis. If the fluid comes away in spurts under pressure the 
probability of serous meningitis, sinus-thrombosis, or more rarely 
brain abscess, is increased. A clear fluid without bacteria or 
coagulating elements indicates probable diagnosis of meningitis, 
toxic (?) or tuberculous. A clear or yellow or slightly turbid fluid 
with predominating lymphocytosis, or the tubercle bacilli, indicates 
tuberculous meningitis after clinical elimination of other causes of 
lymphocytosis, even if there are no tubercle bacilli present. An 
opalescent or purulent fluid, forming a coagulum with predominating 
polynucleosis, and eventual presence of various micro-organisms, 
means acute diffuse meningitis, purulent or non-purulent, cerebro- 
spinal meningitis (provided Weichselbaum's meningococcus is 
present), and if the puncture is hurried — i.e., the fluid aspirated — 
sometimes it indicates a circumscribed menincitis. 



3 Reference to be found in S. J. Kopetzky's Surgery of the Ear. 



GENERAL DIAGNOSIS OF EAR DISEASES. 71 

Apart from the clinical symptoms, lumbar puncture does not 
give the mathematical certainty of establishing the differential 
diagnosis between brain abscess, serous meningitis, meningismus, 
or sinus-thrombosis. It is thus shown that lumbar puncture fails 
precisely for the differential diagnoses of greatest importance to the 
otologist, leaving doubt also as to the existence of a circumscribed 
meningitis. 

The opinions of observers who have made a special study of 
lumbar puncture vary widely as to the practical value of positive 
results of the examination of the spinal fluid — meaning a change in 
the constituency of the fluid — and of negative findings — meaning a 
normally constituted fluid. 

Braunstein summarises the conclusions of Leutert and Schwartz 
laid down at the Versammelung Deutsche Naturfoerscher und 
Aerzte zu Hamberg, 1901, as follows : A negative result, fluid clear 
and normal, definitely excludes the existence of diffuse purulent 
meningitis. A positive result, fluid turbid from increase of leuco- 
cytes, with presence or absence of micro-organisms, demonstrates 
the existence of diffiuse purulent meningitis, or of cerebrospinal 
meningitis (if the meningococcus intracellularis is present). Braun- 
stein does not consider it essential that the leucocytes present must 
be polynuclear, but he admits that the fluid may show turbidity in 
case of brain abscess. 

Korner considers lumbar puncture as a frequent but not 
invariable positive diagnostic measure in otitic leptomeningitis. He 
makes the reservation that a fluid slightly cloudy containing 
bacteria may be found in diffuse as well as in circumscribed menin- 
gitis, and that there may be circumscribed meningitis with a clear 
fluid. 

Differential Diagnosis. — In children especially, tuberculous 
meningitis and cerebral tubercles are often observed, either as a 
complication of tuberculous otitis or as an accompanying result of 
non-tuberculous ear disease ; moreover, tuberculous meningitis is 
often erroneously diagnosticated as ordinary meningitis or even as 
brain abscess. In order to prevent an eventual useless operation 
the examination of the cerebrospinal fluid is resorted to as a diag- 
nostic aid. 

The fluid obtained in these cases is generally clear and trans- 
parent, sometimes greenish yellow or tinged with blood. 

Diffuse purulent meningitis due to various microbes is the most 
commonly observed form of this disorder as a complication of sup- 
purative middle-ear disease. In diffuse suppurative leptomeningitis 
arising as a complication of purulent otitis media, or accompanying 
sinus-thrombosis or brain abscess, the fluid withdrawn by puncture 
is changed both macroscopically and microscopically. The seat of 
the suppurative process is commonly the subarachnoidal (excep- 
tionally the subdural) space. The fluid is accordingly cloudy, 
greenish yellow, sometimes typically purulent, very frequently con- 
taining various forms of microbes, such as the staphylococcus, the 



72 



GENERAL CONSIDERATIONS. 



streptococcus, the pneumococcus, etc., and considerable quantities 
of leucocytes. 

In cerebral or cerebellar abscess uncomplicated by other affec- 
tions, intercranial in their nature, or by sinus-thrombosis, diffuse 
or circumscribed meningitis, the fluid is, as a rule, normally clear, 
without organisms, and yielding no coagulum. After centrifuga- 
tion Lermoyez found the clear fluid to be normal. The quantity of 
the fluid may be altered by the existence of sinus-thrombosis, but it 
generally remains clear. 

As a Therapeutic Measure. — Kopetzky defines the therapeutic 
value of lumbar puncture by calling attention to the fact that it 
affords two ways of therapeutically influencing a given lesion : — 

1. By affording a road for the introduction of medicaments into 
the spinal canal, and from there to the cranial cavity, with the idea 




patient lor the operation of lumbar puncture. 
(Louis Fischer.) 



of producing a resultant action directly upon the cranial or spinal 
lesion. 

2. As a means of producing favorable therapeutic action both 
by relieving pressure as a result of the withdrawal of the excess 
fluid and by the removal of a proportionate quantity of the invading 
pathogenic organisms, and also simultaneously with the with- 
drawal of the fluid, bringing about the removal of the causative 
foci of the disease. 

In the application of the first-named principle of lumbar puncture 
therapeutics many drugs have been employed. Sterilized air, sodium 
salicylate, potassium iodide, iodoform, and antitetanus serum are 
some of the many which have been recommended by various 
observers. Generally speaking the plan has not met with favor ; the 
greatest success has attended the introduction of antitetanus serum. 

The second therapeutic principle, that of producing a favorable 
therapeutic result from the withdrawal of spinal fluid, has brought 
forth wide divergence of opinion. We will study some of these 
opinions in detail. 



GENERAL DIAGNOSIS OF EAR DISEASES. 



73 



The therapeutic value of lumbar puncture in meningitis has 
the endorsement and recommendation of many able observers ; thus 
Quincke finds it useful in cases of serous and seropurulent menin- 
gitis. Its good effects in this condition are due to the relief of 
intracranial pressure. 




Fig. 41. — Lumbar puncture needle and syringe. 



In serous meningitis secondary to the exanthemata in children 
Wertheimer reports most favorably on its therapeutic virtue. 
Friedrich, in his recently published book, discusses the forms of 




Fig. 42.— Anatomical illustration sho\ 
lumbar puncture. The cross indicates tin 
Fischer.) 



the place best adapted for 
point of insertion. (Louis 



operative interference in purulent meningitis inclusive of the 
method of repeated lumbar puncture, followed by injection of 
physiological salt solution for the evacuation of pus from the spinal 
canal. He, however, makes a counter-opening into the cranial 
cavity to secure free evacuation of the purulent exudate. 



74 GENERAL CONSIDERATIONS. 

A variety of opinions exists among these various observers as 
to the relief which the measure affords to hyperdistention of the 
cerebrospinal fluid in this form of meningitis. 

Francis Huber is of the opinion that the therapeutic effect of 
lumbar puncture is a great one, and he uses it as a therapeutic 
measure in otitic meningitis, the cerebrospinal type of typhoid, and 
also in cerebrospinal meningitis. 

In addition to the relief of pressure symptoms lumbar puncture 
serves to evacuate with the spinal fluid a large portion of the agents 
of suppuration, microbic and toxic, which have penetrated into the 
subarachnoidal space. 

Dangers of Lumbar Puncture. — In summing up the question 
of the dangers from this procedure one must take a conservative 
position. That it has caused death is undeniable ; a horizontal 
posture lessens the danger (Fig. 40), and aspiration of the fluid is 
to be condemned. The procedure is contraindicated in cases of 
vascular sclerosis and aneurisms of the cerebral vessels, in all 
acute and chronic affections of the central nervous system with- 
out pressure symptoms arising from the spinal fluid, the more so 
since the cerebral vessels are secondarily implicated in many of 
these diseases. The possibility of cerebral hemorrhage should 
always be kept in mind, especially when withdrawing large amounts 
of fluid. Small hemorrhages represent no danger to life ; they 
may, however, exercise an unfavorable influence on the patient's 
future well-being. 

The Technique of Lumbar Puncture. — The instrument em- 
ployed to make the puncture is the Quincke needle (Fig. 41). 
These needles are procurable in three sizes, of different lengths and 
diameters. Each needle is fitted with a stilette to aid its introduc- 
tion. The length of the Quincke needle is from 4 to 10 cm., with 
diameters from 0.8 to 1.6 mm. The point of the needle is bevelled 
at an acute angle terminating at a sharp point. 

The position of the patient is important in order to carry out 
the technique of the procedure easily. The patient should be placed 
on his side, with his back gently curved so as to effect as great a 
separation of the vertebral bones as possible (Fig. 42). 

THE VALUE OF BLOOD EXAMINATIONS. 

(1) Blood count. (2) The differential count. (3) Blood cul- 
tures. The value of blood examinations as a diagnostic feature in 
purulent otitis media, mastoiditis, and the intercranial complica- 
tions occurring in connection therewith has been a subject of con- 
siderable experimentation during recent years. At the present time 
opinions vary in regard to the value of such examinations in puru- 
lent tympanitis and simple mastoiditis; but the majority of 
observers concede its value in sinus-thrombosis and purulent menin- 
gitis. Dench 4 in a study of sixty cases of purulent otitis media 

4 Transactions American Rhine-logical, Otological and Laryngological 
Society, 1908, p. 198. 



GENERAL DIAGNOSIS OF EAR DISEASES. 75 

with mastoid complications, in all of which blood counts were made, 
concludes that where there is no increased polymorphonuclear per- 
centage, an increase in the leucocyte count is absolutely of no value 
in determining the absence of pus in the mastoid in doubtful cases ; 
that where these variations from the normal blood occur in aural 
cases we must look for one of three conditions: (1) Some visceral 
lesion. (2) Some involvement of the soft tissues in the immediate 
vicinity of the wound. (3) For some involvement of the inter- 
cranial structures, either of the brain substance or of the lateral 
sinus. These views are based upon carefully prepared statistics. 

A more detailed study of the leucocyte count shows a consider- 
able increase of leucocytes in nearly all of the cases reported. In 
only eight cases was the leucocyte count below 9000, the range 
being from 9000 to 25,200. The variations were less marked in the 
polynuclear percentage, which varied from 60 to 80 per cent. 

Blood Count. — The normal leucocyte count varies slightly, 
according to different observers. The following table 5 indicates 
the normal leucocyte count in 1 c.c. : — 

Hayem 6000 

Malassez 7500 

Limbeck 8500 

Rieder 7680 

Thoma 8687 

Beckman-Reinecke 7533 

Groeber 7242 

Tumas 6200 

Any considerable increase of leucocytes is, therefore, sug- 
gestive of infection in some portion of the body. In the differential 
count an increase in the percentage of polynuclear neutrophiles to 
the total number of leucocytes is considered significant of infection. 

McKernon and others consider a high polynuclear percentage 
to be particularly significant of lateral sinus-thrombosis, especially 
when accompanied by a high leucocyte count. In the author's 
experience lateral sinus involvement as a complication of otitic 
origin has been thus characterized. The accompanying table 
represents the result of a blood examination in a patient who 
had a purulent blood-clot extending from the lateral sinus, jugular 
bulb and internal jugular vein and torcular to the clavicle. Here it 
is observed that the leucocytes numbered 30,200 with a polynuclear 
percentage of 84 : — 

Patient, H. K. Date November 17, 1908. 

Blood Examination. 

Hemoglobin 

Erythrocytes 4,400,000 

Leucocytes 30,200 

C. I 



Waite D'Hematologie, by Bezangon and l'Abbe, p. 479. 



76 GENERAL CONSIDERATIONS. 

Differential Count. 

Large mononuclear lymphocytes 26.0 

Small mononuclear lymphocytes 3.0 

Polynuclear neutrophiles 84.0 

Mononuclear leucocytes 4.8 

Transitional forms 4.8 

Eosinophiles 

Mast cells 0.8 

Myelocytes 

Basophiles 

Plasmodia 

The following table shows the normal blood-count and the per- 
centages of the polynuclear to the total number of leucocytes (from 
Da Costa) : — 

Blood Examination. 

Hemoglobin 80-100 % 

Erythrocytes 5,000,000 % 

Leucocytes 7406 % 

Differential Count. 

Large mononuclear lymphocytes 4-8 % 

Small mononuclear lymphocytes 20-30 % 

Polynuclear neutrophiles 69-75 % 

Mononuclear leucocytes 

Transitional forms 

Eosinophiles 0.5-5 % 

Mast cells : 

Myelocytes 

Plasmodia 

Basophiles 0.5 % 

Blood-cultures. — Invasion of the blood-current by pathogenic 
micro-organisms is a condition which is known under the term, bac- 
teriemia. This interesting field of research so far as it relates to 
infections of otitic origin has received comparatively little attention 
on the part of those interested in pathological research. Statistics, 
up to the present date wherein blood-cultures have been made in 
otitic cases, have shown positive results in a considerable propor- 
tion of all cases examined, and in many instances the negative 
results obtained have seemed to be of considerable diagnostic value 
in the elimination of general infection as a cause of the symptoms 
indicated in individual ca,ses. 

Libman 6 made 75 blood-cultures in 55 cases. Of these the 
results were positive in 22 cases, 16 of which were fatal and 6 
recovered. Of the 16 fatal cases 2 were streptococcus mucosus 
meningitidis. His positive results were almost entirely in cases of 
sinus-thrombosis and meningitis. There were positive results in 
but 2 cases of otitis media purulenta, both of which recovered, and 
without any record of examination of the jugular bulb. In simple 
mastoid cases, even with extradural abscess, there was bacteremia 
in but one. 

6 Archives of Otology, vol. xxxvii, No. 1, 1908. 



GENERAL DIAGNOSIS OF EAR DISEASES. 77 

Blood-cultures were made in 26 cases of sinus-thrombosis with 
17 negative results and 9 deaths. All positive blood-cultures in 
these cases showed streptococci. He believes that blood-cultures 
may be negative under the following conditions : — 

1. Bacteria may have escaped into the blood-current and all 
may have been killed off. Possibly a blood immunity is acquired. 

2. Below the purulent clot there may be a non-infected clot, 
or an infected clot none of which breaks off, 

3. A bacteremia may be prevented by tying the jugular vein. 
In such cases metastases (due to bacteria lodged early) may come 
some days after the blood is free from bacteria. All the foci in 
which bacteria have been deposited do not show activity at once. 

4. The patient may have sinus-thrombosis ; there may be 
secondary foci in the lungs, but the bacteria may not escape into the 
general circulation. 

Libman's conclusions are as follows : — 

Significance of Negative Blood-cultures. — 1. If the mastoid has 
been exposed and there is no trouble in the sinus or brain, a negative 
finding will point against a continuance of the symptoms being due 
to a general infection. In such cases one may find that the patient 
has developed tuberculosis, may have rheumatism, or may have 
developed some other intercurrent disease. 

2. If the blood-culture should be negative and the symptoms 
continue, whether there is a sinus-thrombosis or not, acute endo- 
carditis can be excluded. 

3. If there has been a sinus-thrombosis and bacteria have been 
present in the blood and the jugular vein has been tied, a negative 
culture will show that the general invasion has been stopped. 

4. Occasionally a negative blood-culture has been of value in 
cases with a clinical picture of rheumatism coming on in a person 
who has otitis media or mastoid disease. It is very valuable in such 
cases to know that we are not dealing with an arthritis due to 
general invasion by known bacteria. 

Significance of Positive Blood-cultures. — 1. A positive blood-cul- 
ture indicates a general invasion. A positive streptococcus blood- 
culture in Libman's experience nearly always points to the presence 
of sinus-thrombosis. 

2. If the sinus has been operated upon and the patient is not 
doing well, a continued presence of streptococci in the blood shows 
according to Libman that the local focus has not been sufficiently 
dealt with. If the local focus has been thoroughly dealt with," 
streptococci generally remain in the blood only when endocarditis 
has been established or when the bacteria are multiplying in the 
blood. The establishment of endocarditis in these cases occurs, 
according to this observer's experience, quite infrequently. Multi- 
plication of streptococci in the blood in such cases is also not fre- 
quent, so that a positive result continued after operation most often 
means that there is further trouble locally. 

3. If the streptococci have been present in the blood and the 
sinus has been explored and the jugular vein has not been tied, 



78 GENERAL CONSIDERATIONS. 

continued presence of organisms in the blood may give the indica- 
tion to tie the jugular vein. 

4. If the infecting organism in the ear has been the strepto- 
coccus, and the pneumococcus should be found in the blood-culture, 
the suspicion would be aroused that the patient was developing an 
intercurrent ordinary pneumonia. 

5. In cases in which there is a question as to whether the 
patient has developed typhoid fever or a complication of otitis 
media, the presence of bacilli in the blood would prove that the 
patient had typhoid fever. 

6. In a certain number of cases in which the ear phenomena 
are very slight or in which one is not ready to trace marked clinical 
phenomena to an old otitis, the presence of organisms in the blood 
may give the indication to explore the mastoid and surrounding 
parts if there be no other focus found through which the bacteria 
could gain access to the blood. Libman had 3 such cases which 
were operated upon by Gruening, and in 2 of these sinus-throm- 
bosis was found, and in a third mastoid disease. All the patients 
recovered. In a fourth case which concerned a comatose man, 
streptococci were found in the blood and there were metastatic foci 
present in the body. The only possible entrance point found was 
an otitis media. The patient was in too poor a condition for opera- 
tion, but the autopsy showed that a sinus-thrombosis was present. 

To the significance of positive blood-cultures special emphasis 
should be given to the almost universal presence of the strepto- 
coccus in cases of sinus-thrombosis. This statement is abundantly 
confirmed by reports which have from time to time appeared in 
medical literature. Leutert in 4 cases of sinus-thrombosis found 
the streptococcus in all. 

Libman concludes that "it may be affirmed that blood examina- 
tions and blood-cultures possess considerable diagnostic value, 
especially in relation to the complications of purulent otitis media, 
and, while they in no wise supersede or attain the importance which 
should be given to the value of clinical evidence, it is very probable 
that many of the conclusions here cited will have to be modified as 
we learn more of the subject of bacteremia, inasmuch as the 
technique of blood-cultures has not as yet been sufficiently 
developed, and the examination of a sufficient number of controls 
has not been made in order to. render the above conclusions satis- 
factory for clinical guidance." 

Libman's conclusions have been controverted in large measure 
by Wright. 

In a series of experiments conducted by Wright in the labora- 
tory of the Manhattan Eye, Ear and Throat Hospital subsequent 
to those of Libman (February to March, 1909) blood-cultures were 
made in 55 cases of purulent otitis media from the clinics of 
Phillips, Berens, Duel and McKernon, and 2 additional cases of 
purulent frontal sinusitis. The results were reported by Wright 
and Duel. 7 



Transactions of the American Otological Society, 1909, p. 366. 



GENERAL DIAGNOSIS OF EAR DISEASES. 79 

These were all adults and in some instances more than one 
culture was made. Positive bacteremia was found in 16. Of the 
latter, 4 presented clinical symptoms of lateral sinus-thrombosis 
and were operated upon. In 2 a clot was found, but none was dis- 
covered in the others. Another case had acute purulent labyrin- 
thitis and leptomeningitis. One was a simple case of purulent 
otitis media. Bacteremia also was present in the 2 cases of 
purulent frontal sinusitis. One of these had meningitis. The 9 
remaining cases were those of ordinary acute purulent otitis media 
and acute mastoiditis without complications, and all promptly 
recovered after operation. Regarding the type of infection, strep- 
tococci were present in 14 and pneumococci in 2. The conclusions 
drawn by Wright and Duel are as follows : — 

"It is significant that streptococcsemia was present in all of the 
cases presenting clinical symptoms of sinus-thrombosis, and in the 
case of diffuse leptomeningitis ; however, it is none the less signifi- 
cant, from another point of view, that, in 9 cases without any 
alarming symptoms of further complications, 7 had streptococci and 
2 pneumococci in the blood. 

"It seems perfectly evident that a bacteremia occurring in the 
course of a purulent otitis can by no means be considered sufficient 
cause for invasion of the sinus in the absence of other definite 
clinical symptoms. 

"The fact that Libman found a bacteremia in 7 out of 10 of 
Gruening's cases, and that we found it in all cases in whjch the 
clinical symptoms were pathognomonic of sinus-thrombosis would 
seem to make it a valuable additional sign in connection with other 
definite clinical symptoms. 

"A review of the histories and charts of the 41 cases of mastoid- 
itis in our series in which blood-cultures were negative reveals the 
interesting fact that many of them showed temperatures and passed 
through a much stormier course subsequent to operation than the 
9 cases which showed a bacteremia without other symptoms. 

"As the quantity of blood drawn is only something like a 
thousandth part of all the blood, it naturally follows that the pro- 
portion of cases actually having bacteremia must be much higher 
than our figures indicate. 

"At least we have proved that a bacteremia does exist in such 
mild cases. Naturally all its limitations have not yet been 
investigated." 

It is the opinion of the author that, in the present state of our 
knowledge, it is unwise to place undue reliance upon blood-cultures, 
even when positive, unless they are verified by actual clinical 
symptoms. 



CHAPTER VIII. 

GENERAL THERAPY OF EAR DISEASES. 

A chapter on general therapy is introduced for the purpose of 
describing certain therapeutic measures which are referred to 
repeatedly in the subsequent chapters of Part I. 

Hydrotherapy. — Water as a remedial agent in the treatment of 
affections of the ear is employed by various methods and for a 
variety of purposes. Douching or syringing applied by means of 




43. — The piston syringe in use. 



the fountain bag, piston syringe, or Fowler suction apparatus intro- 
duced into the external auditory canal reaches the membrana 
tympani and the tympanic cavity, when the drum is perforated, and 
is of value for the following purposes : — 

1. For the Removal of Cerumen, Foreign Bodies, Pus, Cho- 
lesteatoma, or Other Debris. — In removing cerumen, foreign bodies 
and large cholesteatomatous masses, warm sterile water will 
usually suffice, and the piston syringe (Fig. 43) enables the operator 
to control the force of the current (Chapter XI). The Fowler 
suction douche (Fig. 44) and the Lucae douche, both acting 
on the same lines, are the most effective methods for the removal of 
pus from the external meatus or open tympanic cavity. 

The Fowler apparatus consists of a glass bell, so designed that 
its rim fits accurately about the auricle, wholly inclosing same, 
preventing any back flow or accumulation of fluid from wetting the 
(80) 



GENERAL THERAPY OF EAR DISEASES. 



81 



patient or those administering the treatment, and subjecting the 
meatus to no pressure or possible traumatism. From the top and 
centre of the glass bell projects a nipple, for connecting the appara- 
tus with its source of fluid supply — a fountain syringe. Projecting 
inward from the nipple is a nozzle, glass in its proximal and soft- 
rubber tubing in its distal portion. 

The arrangement is such that this soft-rubber tubing can enter 
the external auditory meatus, taking a direction inward, downward, 
and forward, thus coinciding with the axis of a normal canal. 

The nozzle extends about one-half inch beyond the rim of the 
bell in order that the fluid used may properly irrigate, and the' end 
of the nozzle remain necessarily at a safe distance from the deeper 
portions of the canal. 

On the circumference of the bell is situated the outlet nipple, 




Fig. 44. — The Fowler suction bell douche. 

to be connected with rubber tubing, the latter draining into a wash- 
stand basin or any suitable receptacle. 

The apparatus being made of glass insures at all times a.clear 
view of the parts under treatment and makes cleansing and steriliz- 
ing easy. 

The apparatus irrigates safely, efficiently, and simply, but does 
more, it irrigates in the presence of a partial vacuum, brought about 
by the tight joint between the rim of the bell and the side of the 
head about the ear an,d by the syphonage through the drainage tube 
constantly tending to produce a vacuum (Fig. 45). 

It draws the pus, detritus and inflammatory exudate to the 
surface and the irrigating fluid washes them away. It leaves the 
tissues clean, and without the boggy appearance resulting from 
ordinary irrigations. It produces a combined active and passive 
hyperemia locally in and about the ear with all the concomitant 
benefits claimed for this treatment (Fig. 46). 

The solution employed for douching may be warm sterile 
water, warm sterile normal salt solution, or a solution of bichlorid 
of mercury varying from 1 to 3000 to 1 to 5000. Any preference 

c 



82 



GENERAL CONSIDERATIONS 



for the last-named solution must depend solely upon the germicidal 
power which it may exert. The entire cavity after douching should 
be wiped with cotton pledgets. 

2. Sterilization of the External Auditory Canal. — After cleans- 
ing and scrubbing the external ear the canal should be subjected to 
a thorough douching with a large quantity of a solution of bichlorid 
of mercury, 1 to 5000, preferably by means of a fountain bag, and 




Fig. 45. — The suction douche applied to the ear, showing the indrawing of 
the auricle resulting from the partial vacuum within the glass bell. 



then wiped dry again with sterile cotton. When the drum is intact 
the sterilization is made more effective by filling the canal with 95 
per cent, alcohol for a few minutes after the preliminary douching. 
It is quite impossible by any process to render the external audi- 
tory canal absolutely sterile. 

3. Reduction of Pain and Inflammation. — The hot-water douche 
is of much value for the relief of pain in acute catarrhal otitis media, 
the early stages of acute purulent otitis media, and other aural 
conditions wherein the application of heat is indicated. One to 
three quarts of water, at a temperature of 110° F., allowed to flow 



GENERAL THERAPY OF EAR DISEASES. 83 




Fig. 46. — The suction douche apparatus complete, showing the 
supply bag, rubber tubing, etc. 

into the ear from a fountain syringe elevated four or five feet from 
the patient's head, is gratefully borne and may be repeated at half- 
hour intervals if necessary. The force of the stream should not be 
sufficient to produce traumatism or injury to the soft tissues. 

4. Water Massage. — Massage by means of the douche has its 
advocates. The ordinary car or fountain syringe is the instrument 
commonly employed for this purpose, a small rubber tube being 



84 GENERAL CONSIDERATIONS. 

drawn over the tip and allowed to project slightly. In this manner 
the walls of the auditory canal are protected from injury by the 
syringe, and the introduction of the instrument into the auditory 
entrance is made without risk. The water used in the ear must be 
warm, since cold water causes extremely unpleasant sensations 
upon entering the external meatus, often evoking severe vertigo. 
The temperature best borne is 110° F. When perforations of the 
membrana tympani are present ordinary water sometimes causes 
considerable irritation of the mucous lining. This may be avoided 
by the addition of two teaspoonfuls of common salt to the quart 
of water. 

The pressure at which water massage is employed is of impor- 
tance, and must be gauged according to the symptoms produced, but 
in no event should the force be sufficient to cause traumatism. 
Forcible water massage may also give rise to severe vertigo and 
pain, and it may become a dangerous procedure when forcibly 
brought into contact with necrotic portions of bone, or by the 
entrance of the fluid directly into the labyrinth through a gap in 
the labyrinthine capsule. 

AYater massage should always be carried out slowly and care- 
fully, and it should be interrupted at once upon the first evidence 
of pain or vertigo. Before introducing the tip of the syringe into 
the auditory meatus all air should be expelled by allowing some of 
the fluid to escape from the syringe tip. 

AYater massage may also be effected by means of the suction 
douche heretofore mentioned. After adjusting the glass ear piece 
by intermittent compression upon the outlet tube, the column of 
water is forced inward and outward. 

Contraindications to the Use of the Water Douche.— The ear 
douche induces vertigo in some persons. This occurs more often 
when perforations of the drum are present. Vertiginous attacks 
are sometimes of sufficient severity to render the reclining posture 
necessary for some time. Nausea occasionally accompanies the 
vertigo. Some patients are enabled to avoid vertigo by assuming 
the reclining posture while douching; others prevent the attack 
by varying the temperature of the water. There remains a small 
percentage both with and without perforations, who cannot employ 
the ear douche under any circumstances on account of the persistent 
vertigo and nausea. 

Pain is rarely caused by the douche, but when it is experienced 
it will be found that the water is too hot or too cold. Pain also 
occasionally occurs when water fills the tympanic cavity through a 
small perforation in the upper portion of the drum membrane and 
is thereby retained. 

Tinnitus may be increased by the water douche, the increase 
being more common in purulent cases. 

In all instances sterile water only should be employed for irri- 
gation, inasmuch as a strong current of water may become the 
causative factor in the entrance of micro-organisms into the 
tympanic cavity. The author has never personally observed serious 



GENERAL THERAPY OF EAR DISEASES. 85 

accidents resulting from the forcible use of the water douche ; never- 
theless, such have been reported. 

The canal should be thoroughly dried with pledgets of cotton, 
after bending the head toward the affected side to allow the escape 
of the surplus fluid. In purulent cases, especially when acute, after 
drying it is advisable to close the external auditory meatus with 
sterile gauze in order to guard against further contamination. The 
same precaution should be observed in order to prevent the 
entrance of water into the tympanic cavitv during bathing. 

External Applications of Hot and Cold Water. — The water bag 
and coil are employed for the purpose of reducing inflammation and 
controlling pain. A specially constructed Leiter ear coil (Fig. 47) 
is made to fit closely about the ear and over the mastoid process. 
Applications of cold in the form of the ice coil have been exten- 
sively employed for the purpose of reducing mastoid inflammation 




Fig. 47. — Leiter ear coil. 

and inflammatory conditions of the external and middle ear. The 
procedure relieves pain, but its employment for mastoiditis is looked 
upon with disfavor by most otologists. Except for a few hours 
during the initial congestive stage of the disease, it is always con- 
traindicated, inasmuch as it produces considerable local anesthetic 
effect, thereby masking the true symptoms of the disease without 
being curative. In the treatment of inflammatory conditions of the 
external and middle ear the cold may be applied around the ear 
and over the carotid region along the neck. For the latter purpose 
compresses may be used instead of a coil. Impermeable paper, 
waxed cloth, etc., are never to be used for covering the compress. 
Winternitz believes that cold compresses placed over the region of 
the carotid artery produce sufficient stimulation to contract its 
walls. 

The hot-water bag is a valuable appliance for the relief of aural 
pain, especially that which accompanies acute" otitis media, furuncle 
of the canal, and otalgia of reflex origin. Tt is gratefully borne 
and produces nn ill effects. Tt may be used continuously or at 
intervals, but the temperature should not be sufficiently high to 
burn or scald the skin. 

Hydropathic Applications. — In hydropathic institutions it has 



86 GENERAL CONSIDERATIONS, 

been observed that patients suffering from deafness with subjective 
ear noises due to chronic catarrhal otitis media, whenever the body 
is subjected to warm hydropathic packs lasting for an hour or so, 
are sometimes greatly improved in hearing and relieved of tinnitus 
for varying periods of time. Occasionally the same results are 
obtained in isolated cases of disease of the auditory nerve, espe- 
cially when due to syphilis. Urbantschitsch claims that marked 
perspiration resulting from active physical exertion may cause a 
notable decrease in deafness and subjective ear noises, the symp- 
toms all recurring subsequent to the cooling off of the body. 

Air-douche Therapy. — The air douche is employed for both 
diagnostic and curative purposes, first, by forcing air vapors or 
fluids into the Eustachian tube and tympanic cavity, and, second, 
by pneumomassage or currents of superheated air through the 
external auditory canal. 

In the first variety the mode of entrance is either through a 
catheter (Fig. 21) passed into the faucial opening of the Eustachian 
tube, or by condensation of the air contained in the nasopharyngeal 
space by means of the Valsalva or Politzer method (Chapter II). 

The diagnosis of Eustachian obstruction, and to a slight extent 
the mobility of the membrana tympani, is dependent upon cath- 
eterization or Politzerization (Chapter II). 

The mobility of the membrana tympani and ossicles is more 
effectually determined by means of the pneumatic otoscope (Fig. 
26), which permits the surgeon to induce suction and condensation 
of the air confined in the external. meatus and to observe the move- 
ments of the drum membrane. 

Intratympanic Medication by Means of the Catheter. — The 
treatment of the inflammatory affections of the tympanic cavity 
requires some direct application to the diseased areas, a procedure 
of considerable difficulty except when large perforations are 
present. In the absence of perforations the only means of reaching 
this cavity is through the Eustachian tube. Whenever the oro- 
pharynx is clear, with a sterile catheter any bland sterile fluid may, 
in small quantities, be introduced into the tubal canal without fear 
of inflammatory reaction. Neither is there any valid objection to 
the introduction of slightly astringent or otherwise non-irritating 
medicated fluids into the Eustachian canal. Fluids introduced in 
this manner rarely enter the tympanic cavity, but are deposited 
along the walls of the tube. A minute portion of fluid is taken care 
of by the membranous lining of the tympanic cavity not only with- 
out irritation but with benefit. The chief benefit to be derived may 
be expected from tubal medication only. 

In the treatment of that form of chronic tubal catarrh which 
is accompanied by an accumulation of exudate, especially in the 
pharyngeal portion, six or eight drops of the appropriate medicated 
fluid may be dropped into the catheter by means of a dropper or a 
small syringe, and driven into the tube under moderate pressure 
by an ordinary Politzer bag. Too much force should not be used in 
this procedure, the inflation being performed two or three times in 



GENERAL THERAPY OF EAR DISEASES. 87 

succession in order to expel the total amount of fluid from the 
catheter into the canal. A 1 per cent, solution of common salt to 
which may be added sufficient tincture of iodin to give a pale amber 
color has been found to give considerable relief in this variety of 
cases. This solution, however, is readily decomposed, and must 
therefore be prepared for each day's use. Other useful solutions 
are a 2 or 3 per cent, solution of sodium bicarbonate, a 1 to 3 per 
cent, solution of potassium iodid or ammonium chlorid, a 1 per 
cent, solution of ammonium muriate. The author's preference is for 
oily solutions in the form of properly medicated vaselin, several 
formulas for which will be found serviceable. A 2 per cent, solu- 
tion of camphor and menthol in liquid benzoinol gives great relief 
to tubal inflammation, 5 or 6 drops being injected into the catheter 
and forced into the tube with the air douche. These instillations 
also make the tube more permeable for the passage of the Eusta- 
chian bougie. An injection given to facilitate the passage of the 
bougie should not exceed three or four minims. Sterile solutions 
of cocain or adrenalin may be employed in like manner. 

Introduction of Vapors into the Middle Ear. — In the presence 
of an intact membrana tympani it is not probable that medicated 
vapors introduced into the Eustachian canal through the catheter 
can be forced to enter the tympanic cavit)^ even in limited amounts, 
but the column of air contained in the middle ear is displaced and 
made to advance and recede by this procedure, resulting in a 
gradual diffusion of the vapor employed. 

For medicinal purposes the Dench middle-ear vaporizer (Fig. 
21) is a useful instrument, and combines ordinary inflation with 
medication by using vapor-laden air. By pouring into the hard- 
rubber air chamber, which should be lightly packed with" absorbent 
cotton, a solution of equal parts of iodin, camphor and menthol, a 
strong vapor is blown through the catheter into the Eustachian 
tube. This method is recommended as a routine treatment in all 
cases requiring catheterization. It often relieves distressing tinni- 
tus, improves hearing, and tends to retard adhesive inflammation 
and possesses some slight absorbent power. 

Ammoniated vapors are most simply introduced by pouring 
the rapidly evaporating fluid into the bulb of an air douche. In 
cases of difficult Politzerization it is customary to put 2 or 3 drops 
of chloroform into the air douche, taking advantage of the rare- 
faction attending the escape of air by the pressure upon the bulb to 
overcome the obstruction in the Eustachian tube. For the same 
purpose a few drops of a solution of one part of camphor to ten 
parts of ether have been employed. This procedure not only serves 
to aid in the process of Politzerization of the middle ear, but the 
vapors occasionally seem to cause at least a temporary decrease in 
the subjective ear noises, while neurotic patients are sometimes 
sufficiently impressed with the procedure to be entirely relieved. 

Superheated Air. — The employment of the electric heater (Fig. 
48) makes it possible to douche either the Eustachian tube or the 
external canal and membrana tympani with air which has been 



88 GENERAL CONSIDERATIONS. 

warmed to a proper temperature. This is recommended in obsti- 
nate cases of tubal catarrh with tinnitus, and applied through the 
external auditory canal for the relief of pain arising- from intra- 
tympanic inflammations and otitis externa. 

Pneumomassage of the Middle Ear, and Negative Air Pressure 
in the External Auditory Canal. — Alternating condensation and 
rarefaction of air within the auditory canal serves to produce 
vibrations of the drum membrane and the ossicular chain. Oto- 
massage is employed for the prevention of adhesions of those parts, 
with diminished mobility of the sound-conducting apparatus, or for 
breaking down those already formed. If successfully conducted 
the hearing function is often conserved and distressing tinnitus 
benefited. In former years the motive force was derived from a 
small rubber bulb or some form of hand pump, types of which 




Fig. 48. — Electric air heater. 

are those of Lucae, and the rarefactor constructed by Delstanche, 
either of which permits the regulation of changes of air pressure 
in the auditory canal. The control of these instruments is entirely 
within the province of the operator, who may at the same time 
witness the effect upon the drum membrane through the glass 
window in the speculum. Of late the electromotor air pump (Fig. 
3) is almost exclusively employed for the relief of pressure sensa- 
tion and tinnitus, on account of the uniformity of pressure and rare- 
faction produced by the electromotor machinery. The electro- 
motor air pump is a valuable adjunct in the treatment of the chronic 
forms of middle-ear disease when accompanied by adhesions. All 
massage procedures are employed to loosen the adhesions and 
increase the motility of the ossicles. Pneumomassage of the middle 
ear sometimes produces a transitory sedative effect upon the sub- 
jective ear noises of severe chronic catarrhal otitis. Deafness also 
is occasionally favorably influenced by this form of treatment, the 
relief being described by patients as due to a diminution of the 
pressure sensations in the ear and head and sometimes from vertigo. 
The hand otoscope is more positive in results when employed for 
the prevention of adhesions. In labyrinthine disease the intercur- 
rent tinnitus and pressure sensations are usually aggravated by the 



GENERAL THERAPY OF EAR DISEASES. 89 

employment of pneumomassage. Patients with mixed catarrhal 
and labyrinthine deafness are not usually benefited by pneumo- 
massage except when employed for the prevention of adhesions, 
and it should be discontinued whenever it increases the tinnitus 
or aggravates the deafness. It is usually contraindicated when the 
drum membrane is atrophic, even though the ossicles are bound 
down and immovable on account of fibrous deposits, for the suction 
affects only the atrophic membrane and the ossicles are not moved 
thereby. Added to this is the danger of rupture. 

All otomassage instruments should be used with due precau- 
tion, never indiscriminately, and only after ascertaining that the 
case is a proper one for massage. 

The binaural attachment of the electric apparatus is convenient, 
but considerable experience is requisite in order to determine the 
proper suction force and vibratory speed for the individual case. 

It is safer for the inexperienced to employ a window otoscope, 
and ahva}rs under visual inspection, with the drum membrane in 
full view. The excursion of the drum and ossicles may thus be 
noted and all variations observed. 



Fig. 49. — Lucae's pressure sound. 

The first manifestation of pain during the employment of 
pneumomassage is to be interpreted as a sign of exaggerated force, 
especially if accompanied by vertigo or tinnitus. The degree and 
rapidity of the motions of the apparatus should be relatively dimin- 
ished. Whenever this form of treatment is followed by symptoms 
of pressure, tinnitus or vertigo, or even if the patient states that he 
does not feel as well after the treatment, it should be discontinued. 

Pressure-sound Massage. — Another form of massage recom- 
mended by Lucae is conducted by means of the pressure sound 
which bears his name (Fig. 49). The purpose of the pressure sound 
is to mobilize the ossicular chain and prevent adhesions. The small 
cup-shaped end, thinly wrapped in cotton and moistened, is applied 
to the short process, the motor force being supplied by the oper- 
ator's hand. This method is more painful and does not secure any 
better results than pneumomassage. 

Vibratory Massage. — Electric vibratory massage (Fig. 3) is a 
valuable aid in the treatment of chronic non-suppurative ear affec- 
tions, its chief benefits being relief of tinnitus and intratympanic 
pressure. Unlike pneumomassage it is often well borne in laby- 
rinthine and mixed cases. The soft-rubber cup-shaped tip gives 
better results than hard rubber. It relieves tension and produces 
a decidedly soothing effect upon the nerves in a class of patients 
who are subject to marked depression and fits of despondency. It 
may be used only for from five to. ten minutes and applied about 
the ear, face and cranium. The points of application are: (1) to the 
point of the chin ; (2) at the anterior edge of the attachment of the 



90 GENERAL CONSIDERATIONS. 

masseter muscle to the lower jaw; (3) in front of the tragus; (4) 
completely over the opening of the external auditory canal ; (5) 
above the ear; (6) upon the mastoid process; (7) at the occiput. 
These points are selected because they seem to carry the vibrations 
more directly to the region of the ear. Many patients seem to 
receive benefit from the vibratory massage who believe they are 
harmed when pneumomassage is employed. In any estimate of the 
results of the treatment, the personal equation must be given a 
large place. 

Instillation of Eardrops. — Eardrops are employed (1) for soft- 
ening masses of cerumen ; (2) as dissolvents for the removal of 
inspissated crusts, scales, mucus and pus; (3) as antiseptics and 
deodorants ; (4) for astringents, styptics and cauterants in the 
middle ear; (5) for local anesthesia, all of which are fully described 
in the various special chapters. In order to properly instil drops 
into the external auditory canal the patient should either lie down 
or the head should rest horizontally upon a stand or table with the 
affected ear upward. The canal may thus be filled from a glass 
dropper. The entrance is also facilitated by gently moving the 
external ear in a somewhat rotary manner, at the same time lifting 
it. Very cold fluids should never be used. Oils are contraindicated 
except as a dressing for dermatitis, or for scaly eczema of the 
external canal. 

A simple method for heating eardrops is by immersing the 
uncorked bottle containing the fluid in hot water. After the instilla- 
tion the ear should remain in the same position for four or five 
minutes, until the fluid has had sufficient opportunity to permeate 
the entire cavity. Should both ears be under treatment the same 
process may be repeated. If necessary to save time one canal may 
be entirely filled with the fluid and the entrance corked by a firm 
plug of absorbent cotton, the remaining one then receiving the 
same treatment. Various kinds of drops are used according to the 
requirements of the case. 

Insufflations. — At the present time the insufflation of powders 
into the external auditory canal and middle ear for medicinal pur- 
poses is extremely limited. Until recently all cases of purulent 
otitis media were treated by insufflating the external canal and 
possibly the tympanic cavity with boric acid, or some other form 
of medicated powder. This form of routine treatment has, very 
properly, been abandoned, for, instead of absorbing and devitalizing 
the pus, the powder seemed to dam up the discharge, adhere to the 
walls of the canal, and thus become most difficult to remove, even 
by forced syringing, and altogether do more harm' than good. A 
small quantity of boric acid insufflated directly into the tympanic 
cavity through a long cannula during the last stage of middle-ear 
suppuration hastens the healing process by direct contact with the 
tissues upon which its effect is desired. It is not uncommon in 
clinic patients to be obliged to remove masses of iodoform or 
boric acid which have remained in the external auditory canal 
for several months. 



GENERAL THERAPY OF EAR DISEASES. 91 

Local Anesthesia in Operative Procedures upon the Ear. — 

The local application of solutions of cocaine, eucain or alypin to the 
lining of the auditory canal or an intact membrana tympani 
produces little or no anesthetic effect. If injected underneath the 
skin at or near the point of incision anesthesia is produced, but at 
the expense of a painful needle prick. Efforts have been made to 
augment the anesthetic effect by the addition of other drugs, and it 
has been found that a solution made up of equal parts of the crystals 
of cocaine, carbolic acid and menthol, or that recommended by 
Grey 1 which is as follows : — 

B- Cocaine crystals gr. xij — xxiv; 

Anilin oil 3j ; 

Absolute alcohol 3j ; 

has considerable anesthetic effect, especially upon the mem- 
brana tympani. These solutions act slowly and require at least 
twenty minutes for full anesthetic action. Before instilling the 
anesthetic solution the head should be bent, with the affected ear 
turned upward and the drops held firmly in position by means of 
a pledget of cotton pressed into the external meatus. Symptoms 
of toxemia rarely occur unless large perforations already exist. 
Anesthesia thus produced is usually sufficient to considerably lessen 
the pain of a paracentesis or abscess incision in the canal. A hypo- 
dermatic injection of a 1 per cent, cocaine solution made at the point 
of attachment of the membrane with the upper wall of the canal 
( Fig. 180) will produce sufficient anesthesia to admit of para- 
centesis, and would be ideal for this purpose but for the pain pro- 
duced by the needle puncture, which is almost as severe as the 
paracentesis. 

When the first-mentioned formula is employed it becomes 
necessary afterward to instil a few drops of alcohol into the canal 
in order to counteract the escharotic effect of the carbolic acid. 

According to Neumann, Day and Beck, simple and radical 
mastoid operations may be performed under local anesthesia by 
making deep injections of cocaine posteriorly between the mem- 
branous and bony canal walls, and subperiosteally over the cortex 
and at the zygoma, the mastoid tip and midway between these two 
points (Fig. 50). The solution should never be stronger than 1 per 
cent, cocaine in 1 to 5000 adrenalin. 

The removal of granulation tissue from the external canal or 
tympanum, either by curet, snare (Fig. 179) or cautery, is rendered 
comparatively painless by instilling the solution of cocaine, menthol 
and carbolic acid, or by injecting a few drops of a 4 per cent, solu- 
tion of cocaine into the growth. -When perforations exist consider- 
able anesthetic effect may be produced by the intratympanic appli- 
cation of the above solution, nr by applying the crystals of cocaine 
direct. A 10 per cent, solution of cocaine in a 1 to 5000 solution of 
adrenalin, instilled into the tympanic cavity through a perforation, 
insures good anesthesia and controls hemorrhage at the same time. 

1 British Medical Journal, April, 1900. 



92 



GENERAL CONSIDERATIONS. 



Dangerous physiological effects of cocaine result from the careless 
use of excessive quantities or strong solutions. 

Before instilling cocaine the ear should be thoroughly cleansed 
with a warm normal salt solution and the whole area carefully 
dried. There is less danger of inducing toxemia from a few crystals 
applied directly to the part to be anesthetized than from a weak 
solution indiscriminately applied to a large mucous surface. 

Local anesthesia thus produced is quite sufficient in plucky 
individuals for the performance of ossiculectomy, with curetment 
of the attic and tympanic cavity, with the advantage to the operator 
of the upright posture and less hemorrhage. It is contraindicated 
for this operation in timid and neurotic patients and when extensive 
curetment is required. 

Pulverized orthoform blown upon the mucosa produces a 
similar effect, the anesthetization being more permanent. The sub- 




Fig. 50. — Points for the subperiosteal injection of cocahu 
anesthesia of the mastoid process. 



to induce local 



cutaneous injection of a 1 per cent, solution of cocaine has proved 
sufficient for the painless removal of portions of the concha, and 
cancerous conchas have been removed under local anesthesia. 

Ethyl chlorid is useful for minor operations about the ear in 
locations where it may be successfully applied by the usual method. 

Incision of the Drum Membrane (Paracentesis). — Incision of 
the membrana tympani, or paracentesis, the indications for which 
are more fully described in Chapter XVIII, is an operation which 
is performed for the purpose of obtaining access to the middle ear 
from without, and of releasing retained secretions from the tym- 
panic cavity proper and its accessory sinuses. It is chiefly employed 
to facilitate the drainage of pus in purulent otitis media, thereby 
becoming a valuable curative measure, and its performance for this 
purpose meets with the universal endorsement of otologists. The 
operation is rarely indicated in catarrhal inflammations, or for 
diagnostic purposes. 

Preparation of the Patient. — The external ear and canal should 
be sterilized as thoroughly as possible by removing cerumen or 
other debris, with douche or moist cotton probe. Thorough douch- 
ing of the external meatus with a quart or more of solution of 
bichlorid of mercury (1:-1000), at a temperature of 110° F., is the 



GENERAL THERAPY OF EAR DISEASES. 



93 



most effective cleansing measure now employed. Asepsis will be 
more nearly attained by filling- the external canal with alcohol or 
hydrogen peroxid for about five minutes immediately after using 
the bichlorid douche, the affected ear being turned upward, and 
the hairy portions rubbed with a cotton probe saturated with the 
same solution. The deeper portions of the canal cannot be scrubbed 
without breaking down the delicate dermoid lining. 

The nose and nasopharynx should be thoroughly cleansed of 
retained secretions, in case a subsequent inflation may be required. 

Slides for smears or a culture medium should be at hand in 
order that an uncontaminated specimen of the infection may be 
secured for a laboratorv examination. 




Fig. 51. — Electric ear speculum. 



The hands of the operator and all instruments are to be thor- 
oughly sterilized and no precaution neglected to prevent the ingress 
of infection from without, always an unfortunate occurrence inas- 
much as secondary infection complicates the case and tends 
toward chronicity. Under all circumstances a paracentesis is an 
extremely painful procedure, and especially so when performed 
upon a swollen and inflamed drum membrane, in a patient who has 
become hypersensitive from long suffering and loss of sleep. 
Whenever possible it should be performed under an anesthetic. 
The ideal anesthetic for this purpose is nitrous oxid gas, as narcosis 
produced by nitrous oxid gas is of sufficient length to allow of a 
complete and thorough paracentesis, and at the same time is 
quickly recovered from without disagreeable sequelae. 

If for any reason a general anesthetic cannot be given, much 
of the pain may be alleviated by an instillation of the local anesthe- 
tic mentioned on page 91 of this chapter. 



94 GENERAL CONSIDERATIONS. 

If performed without an anesthetic the incision should be made 
with great preciseness and speed and completed before the patient 
has time to interfere. 

The field of operation is to be illuminated either by bright 
reflected light, electric headlight (Fig. 5), or a speculum in which 
a small electric illumination lamp is concealed (Fig. 51). A 
speculum large enough to slightly stretch the soft tissues of the 
external canal gives the best view of the drum. With local anes- 
thesia or nitrous oxid gas the operation is performed in the upright 
posture, which retains the landmarks in their upright position. 
while in the recumbent position a reversal of the relative position 



Fig. 52. — Paracentesis bistoury. 

of the landmarks occurs, which the operator must bear in mind. 
The incision should be made with a sharp paracentesis bistoury 
(Fig. 52), its location depending upon the conditions present in the 
individual case. The spear-shaped lancet ( Fig. 53) should be dis- 
carded for this operation, inasmuch as an incision — not a puncture 
— is desired. 

In purulent. cases with decided bulging of the drum membrane, 
and in other forms of inflammation or traumatism attended with 
sufficient exudate into the tympanic cavity to cause bulging and 
displacement of the drum membrane, the incision should divide all 
that portion of the drum at which the bulging is most prominent. 
Generally this will be found in the posterior inferior quadrant ( Fig. 
54), but in severe cases the entire drum, attic and the postero- 
superior canal wall may be intensely engorged and swollen. 



Fig. 53. — Spear-shaped lancet. This instrument should be discarded 
from the armamentarium of the aurist, inasmuch as incision of the drum 
membrane has replaced puncture. 

A paracentesis incision should always be large in order to 
allow free escape of the secretion into the auditory canal and further 
to obviate the necessity of repeating the procedure. The incision 
should be so placed that the opening will extend from near the 
floor of the canal upward through the entire bulging portion of the 
membrane, carefully avoiding contact with the incus and stapes 
(Fig. 55). American surgeons usually incise the drum from below 
upward, while among foreign surgeons the reverse is true. The 
point of the instrument must not penetrate too deeply into the 
tympanic cavity, although some authorities recommend the division 
of the inner wall of the tympanic cavity in the region of the prom- 
ontory, for the purpose of local depletion — a procedure which is 



GENERAL THERAPY OF EAR DISEASES. 



95 



of doubtful value and liable to open up a new field for infection to 
enter; nor should the ossicles be wounded. The incision should be 
so arranged that the greatest possible number of radiating fibres 
will be severed, which will tend to promote the gaping of the 
wound and prevent too rapid closure. An incision running parallel 
to the malleus shaft in the posterior quadrant (Fig. 56) serves this 
purpose. In severe purulent cases the bulging involves Shrapnell's 




Fij 



54. — The heavy dark line indicates the incision commonly required 
for opening the drum membrane. 



membrane, with infiltration of the posterosuperior wall. The fact 
that Shrapnell's membrane consists of but two layers, the cutis and 
the mucosa, with the absence of the strong lamina fibrosa, accounts 
for its lack of resistance to pressure from pent-up exudate, and 
explains why it quickly distends. In order to more perfectly drain 
the epitympanic space, as well as for purposes of local depletion, it 
is wise to incise it (Fig. 56, A), but the indications are best fulfilled 




Fig. 55. — A lateral view of the inner portion of the external auditory 
canal and tympanic cavity, showing the relation of the ossicles to the 
membrana tympani. 

by extending the original incision upward through the posterior fold 
(Fig. 54), thus severing the numerous reduplications of Shrapnell's 
membrane. If further depletion is desired, the incision may be 
extended outward through a portion of the drooping canal wall. 
The latter procedure is recommended by Dench and others. 

Existing perforations in acute cases are usually too small or 
are located too high up to permit free drainage ; hence, it becomes 
necessary to enlarge the openings. 



% 



GENERAL CONSIDERATIONS. 



If the small perforation is located in the upper segment of the 
drum membrane (Fig. 56, B) the incision should commence at that 
point and be extended downward to the periphery. But when the 
small perforation is located lower down the incision should be 
extended downward to the periphery and upward throughout the 
entire area of bulging (Fig. b7, A). 

It is meddlesome surgery to open the drum membrane for pur- 
poses of exploration or for depletion alone, inasmuch as equally 
effective results may be obtained by local bloodletting elsewhere. 

Immediately following the incision the ear should be douched 
with a warm solution of bichlorid of mercury, 1 : 4000, or normal 
salt solution, through a suction douche (Fig. 46) or fountain 
syringe, and every possible measure inaugurated to prevent the 
entrance of extraneous infection, the watchword being cleanliness 
and free drainage (Chapter XVIII). 

Fig. 56. ' Fig. 57. 





Fig. 56. — Incision of the drum membrane. A, Through Shrapnell's 
membrane. B, From a perforation downward. C, Incision made anterior 
to and parallel with the malleus. 

Fig. 57. — Incisions of the membrana tympani. A, Enlarging a perforation. 
B, Short anterior incision. 



A secondary paracentesis is commonly required on account of 
the tendency to early closure of the wound before the pathological 
manifestations have subsided. 

Depletion by Local Bloodletting. — Depletion locally applied to 
the tissues about the ear in the form of real or artificial leeches, 
wet cups or incision, is employed in the treatment of acute purulent 
and catarrhal otitis media, mastoiditis, acute myringitis, hyperemia 
and hemorrhage within the labyrinth, upon the theory that the 
removal of blood from an inflamed area relieves congestion and 
removes a proportionate quantity of the inflammatory products and 
toxins. The procedure usually results in some relief of congestion 
and pain, but it is somewhat doubtful whether any permanent 
benefit is accomplished, and it is of doubtful value in the treatment 
of purulent mastoiditis. 

The application of the leech is unpleasant and disgusting. Its 
bite heals slowly, with considerable inflammatory reaction, and 
easily becomes infected. Leeches do not readily bite upon skin 
which has been rendered aseptic by the usual methods. In the 
light of modern aseptic surgery whereby almost any quantity of 



GENERAL THERAPY OF EAR DISEASES. 



97 



blood may be extracted through an incision into a previously 
sterilized surface in front of the tragus or a little below it, or upon 
the mastoid process, close to the concha, and the flow maintained 
by means of some form of suction, it would seem timely to elimi- 
nate the leech (Fig. 58). 

Fig. 60 is a suction apparatus which is easily applied about the 
ear, and is preferable to cupping. 

In acute purulent otitis media local bloodletting should never 
supercede paracentesis. The most effective and satisfactory means 
of local depletion in acute aural inflammations of sufficient severity 




,«p 




Artificial leech. Bacon's scarifier and cupping glass. 



to require a paracentesis is to extend the paracentesis incision 
upward and outward into the inflamed and swollen tissues of the 
canal wall, thus dividing the blood-vessels freely and producing 
copious hemorrhage. It has been described as an internal Wild's 
incision. 

Artificially Induced Hyperemia. — In regard to the applicability 
of Bier's method (Fig. 59) in the treatment of ear disease, there 
is a wide divergence of opinion among the various observers 
who have personally investigated its clinical value. It has 
been established, in a general way, that the congestion is readily 
tolerated, and often relieves pain. Acute processes, notably mastoid 
complications with abscess formation, may be very favorably in- 
fluenced, whereas the results in chronic suppurations are unsatis- 
factory. The situation has been concisely outlined in the state- 
ments of Schwartze, to the effect that it is left for further clinical 

7 



98 



GENERAL CONSIDERATIONS. 



research to determine which types and stages of ear inflam- 
mation are adapted to this form of treatment, and for how long a 
time surgical interference may be delayed in its favor. As 
Kopetzky has shown, a certain element of danger is involved in the 
postponement and neglect of urgent surgical intervention because 
of the cessation of urgent symptoms by the use of Bier's treatment, 
the disease often progressing nevertheless. 

In patients with arteriosclerosis or intracranial complications 
it is absolutely contraindicated. By modification of the violent 
acute symptoms, so as to obscure the clinical picture and simulate 
an apparent improvement when the process meantime is steadily 
advancing, the method may lead to serious results. There are two 
factors which clinical experience has shown to increase the pros- 
pects of a successful outcome in this form of treatment: (1) 
timely institution of the congestive hyperemia; (2) selection of 



Fig. 59, 




■The Bier treatment by constrictionband about the neck. 

(Kopetzky.) 



patients having a strong constitution, and free from kidney disease 
or circulatory disturbances. 

In passing, the writer wishes to add that if a careful and dis- 
criminating clinician is essential to the successful outcome of this 
plan of treatment in the field of otology, this remark applies with 
even greater force to its adoption in rhinological cases, where the 
corresponding observations are less numerous, less uniform, and 
less encouraging than in ear patients. 

Vaccine Therapy. — Here is a broad field for research and 
experimentation and one replete with possibilities. The working 
theory of opsonic therapy is outlined by Beck 2 and is as follows : — 

1. Bacteria infecting the body are attacked by leucocytes 
which ingest them. 

2. The number of bacteria which can be ingested is of varying 
quantity. 

3. The number of bacteria which can be ingested depends upon 
their preparation by substances present in the plasma of the blood 
known as opsonins. 

4. Opsonins are supposed to exert some influence upon bac- 
teria, by which they become prepared for ingestion by the leuco- 



2 Transactions American Laryngological, Rhinological and Otological 
Society, 1908, p. 459. 



GENERAL THERAPY OF EAR DISEASES. 



99 



cytes. It has also been found by experiments that normal blood 
varies but little in opsonic strength, while in individuals who are 
infected the opsonic strength is materially lessened. Hence, in 
infected persons with lowered opsonic strength, but few bacteria 
are prepared for ingestion by the leucocytes. 

The opsonic index is founded upon the ratio borne by the 
number of bacteria which become ingested by the leucocytes in 
infected individuals to that of the normal or healthy person. 

Reduced to percentage — if within a given time 10 bacteria are 




Suction apparatus for inducing local hyperemia. (Fowler.) 



ingested by the leucocytes in health while but 5 bacteria of similar 
type are ingested by one infected, the opsonic index of the one 
infected is 0.5. 

The opsonic index is increased by injecting into the infected 
person dead cultures of the particular type of micro-organisms 
(preferably from his own body) from which he is suffering. 

Should future experiments establish the earlier claims made 
by those who have experimented widely, notably Wright, and 
Douglas,-"' the era will mark an epoch-making advance in thera- 
peutics. 

The Hiss Leucocyte Extract. — In the following communication 



3 Proceedings of the Royal Society, vol. lxxii, Ixxiii and lxxvii. 



100 GENERAL CONSIDERATIONS. 

Dwyer gives a brief resume of his experiments with the Hiss leuco- 
cyte extract in purulent affections arising from the ear and nose. 
Several of the cases treated have occurred in the author's service at 
the Manhattan Eye, Ear and Throat Hospital. 

"Every clinician is aware of the importance of the leucocytes 
in the struggle against infection from micro-organisms. The 
method heretofore pursued in treating these diseases has been to 
stimulate and support the patient until either the infection or the 
patient's resistance proved the stronger. Experimental studies 
have seemed to warrant the employment of a more natural and 
hence a more rational method of combating these organisms by 
injecting into the circulation an extract of rabbits' leucocytes, 
which, when thus injected into the patient suffering from such 
infections as arise from the pyogenic organisms, seems to favorably 
modify the course of these infections. The experimental results in 
rabbits and the results obtained in human beings by the treatment 
with this extract were reported by Hiss, the author of this thera- 
peutic measure in the Journal of Medical Research, volume xix, 
No. 3." 

"The results of Hiss were most gratifying. During the last 
year the writer has treated 21 cases with this extract for varying 
periods with gratifying results. Ten of this series were considered 
by the attending surgeons as desperate and probably fatal cases. 
Seven of these, or 70 per cent., survived. In the complete series 
there was, with one exception, some response to the injections of 
the extract, the change generally noted being improvement in the 
general condition and in the delirium. In the majority of cases 
the latter symptom disappeared. In several there was a decided 
change in the temperature, a drop of 2 or 3 degrees taking place 
in a few hours. Four cases of erysipelas, occurring within a few 
days after the mastoid operation, recovered quickly ; the erysipelas 
ceased to spread and the duration of the disease was apparently 
shortened. One of the main points in connection with these cases 
was the fact that the wounds remained perfectly healthy and healed 
in about the average time of an ordinary mastoid wound, which is 
contrary to the usual experience. The cases of pneumonia were 
much improved, as shown by the immediate lessening of the 
dyspnea, the improvement in the pulse and the general condition. 
One case of meningitis, complicating frontal sinusitis, responded 
very quickly to the extract and was discharged cured. Another 
similar case was slightly improved, but eventually succumbed. The 
most striking and satisfactory series comprised those of mastoiditis, 
complicated by sinus-thrombosis. The ligation of the jugular vein 
localizes to a large extent the septic process and prevents further 
infection, but sufficient septic matter has generally been absorbed 
to keep up the symptoms of sepsis for some days and in some cases 
to eventually overwhelm the patient. This class quickly responded 
to the injections and thereby were tided over a crucial period in 
their illness." 

"The reports of others bear out the above results. Floyd and 



GENERAL THERAPY OF EAR DISEASES. . 101 

Lucas, of the department of bacteriology, 4 report 41 cases of 
pneumonia so treated with a mortality of 5, or 12% per cent. This 
death rate is much below the average, as the prevailing mortality 
during the last five years at the hospital where these cases were 
treated was 21% per cent. Also, a comparison of a series of 25 
cases treated with the extract and 25 treated by the ordinary means 
shows a mortality of more than double in the series of the untreated 
cases." 

"Dr. Adrian Lambert, New York City, reports 51 cases of 
erysipelas so treated. His conclusions were that when the injec- 
tions of the leucocyte extract were commenced within forty-eight 
hours of the onset the extract acted almost as a specific. In average 
cases, regardless of the time of inception of the treatment, the 
symptoms were much alleviated, the general condition much 
improved and the complications and sequelae fewer and less severe. 
One of his series was interesting: 6 cases of infants under one year 
of age were treated with the extract with a mortality rate of 33% 
per cent. His previous mortality rate with such cases had been 
100 per cent. The evidence at hand seems favorable to this mode 
of treatment, and my conclusions are as follows : — 

"1. In no cases has the extract done any harm to the patient 
treated. 2. No local reaction was observed at any time and the 
tumefaction produced by the injection of such a large amount of 
fluid .was absorbed with great rapidity. 3. The chief advantage 
from a practical point of view is that the effects of the extract are 
apparent within a few hours after its use. 4. We inject into the 
body only substances which are normally present there. 5. There 
is no necessity of isolating the offending organism as must be done 
in the use of vaccines, and this is of importance in those obscure 
septic cases where we cannot isolate the organism." 

"Such a method of treatment seems peculiarly suitable in the 
treatment of the systemically acute infections with the ordinary 
pus organisms. The consensus of opinion, as gleaned from the 
reports of those who have treated a series of cases with the vac- 
cines, is that the latter are more suitable to chronic cases and that 
in fact much harm may result from their use in the acute infec- 
tions when accompanied by general systemic symptoms. This has 
been the writer's experience, and if we are to use vaccines in such 
cases, then we must revise our whole conception of how antibodies 
and vaccines operate in the system. There are no objections to the 
extract, as the use of the latter does not call for the active participa- 
tion of the system in the process." 

"Analyzing as far as possible the action of the extract, it would 
appear that it does not act through the bactericidal, bacteriolytic 
or phagocytosis-stimulating power, 'but that its marked favorable 
influence on the general condition and in some cases on the tempera- 
ture is in all probability referable to its neutralization of the toxic 
products, that is, ordinarily speaking, to its combating the condi- 
tion spoken of as septic or toxemic." 

4 Harvard Medical School, Journal of Medical Research. 



102 



GENERAL CONSIDERATIONS. 



"The extract is administered subcutaneously twice daily in 
doses of 10 c.c. It may be given more frequently if necessary.- The 
soft tissues either at the back of the abdomen or buttocks should be 
selected for the site of puncture. It is necessary to keep the supply 
of extract in a cool place." 

Blood-pressure. — Hubby 5 has found that the determination of 
blood-pressure (Fig. 302) is sometimes of value in suspected intra- 
cranial complications of suppurative diseases of the ear. The 
Janeway sphygmomanometer was used, the patient always being 
in a horizontal position. He states that it is only of value when 
frequently taken — i.e., several times a day. He found that an 
exploratory operation was indicated in suppurative diseases of the 
ear (other causes of high blood-pressure not being frequent), on the 
finding of high blood-pressure associated with such symptoms as 
beginning edema of the optic papilla, and vertigo. 



5 Medical Review of Reviews, January, 1908. 



SECTION II. 

The External Ear. 



CHAPTER IX. 
SURGICAL ANATOMY. 

The external ear constitutes the most external of the ana- 
tomical divisions of the organ of hearing, and is composed of (a) 
the auricle (pinna) ; (b) the external auditory canal (meatus audi- 
torius externus). 

The Auricle. — The auricle consists of a thin, pliable, irregular, 
fibrocartilaginous framework enveloped in perichondrium and skin. 
The skin is thrown into folds and projections, the most extensive 
of which is at its lowest surface, where a large, loose, dependent 
fold of integument envelops a quantity of adipose tissue, but no 
cartilage. 

The posterior surface of the auricle is generally convex, except 
near its free border, and is fairly smooth, while the anterior surface 
is generally concave, presenting numerous irregularities which form 
elevations and depressions. The attachment of the pinna is by 
extension of its cartilage into the external auditory meatus and the 
continuation of its integument to that of the temporal and cheek 
region. Normally the attachment to the temporal bone is at an 
acute angle. The nomenclature and illustration of the various 
folds, concavities, ridges, crura and notches are found in Fig. 61. 

There are marked variations in the anatomical outlines of the 
auricle within even normal limitations, while malformations, 
anomalies and deformities occur in a variety of forms. Among the 
variations in size it will be noted that the pinna of the male is 
larger than that of the female, the right is usually larger than the 
left, and there is a tendency toward increase in length, in old age. 
Other variations have been noted by alienists in the criminal and 
the degenerate. 

r rhe integument of the auricle is thin, containing sebaceous 
glands, and in some locations hairs. Its attachment to the concave 
surface is considerably firmer than to the convex. There is but 
little subcutaneous fat present except in the lobule. 

A number of rudimentary muscles are found on both the 
anterior and posterior surface of the auricle. These are of ana- 
tomical value only, and are not herein described. 

The arterial supply of the pinna comes from the posterior 
auricular, the occipital and the superficial temporal arteries. 

The pinna receives its sensory nerve supply chiefly from the 
auriculotemporal and the auricularis magnus; the motor supply 

(103) 



104 



THE EXTERNAL EAR. 



is derived from the facial nerve. Numerous lymph channels 
traverse the auricle. 

The External Auditory Canal. — The external auditory meatus 
extends from the concavity of the concha to the margin of the 
tympanic membrane. The outer or cartilaginous portion extending 
inward passes upward and slightly backward, while the bony canal 
extends inward, downward and usually slightly forward, the highest 
level of the canal being at about the junction of the cartilaginous 
and osseous portions. 



Helix 






'•w 




the helix 


\ 








tubercle 




1 






Anthelix 






^SB 






"-" '\, 


\ 










Concha 




/' 


> 


^s 



Fossa triangularis 
Crest of helix 
Tragus 



External auditory 
meatus 



Incisura 
intertragica 



Antitrag^is 
Fig. 61. — The normal auricle with landmarks. 

The cartilage is absent along the superior and posterior 
portions of the canal, its chief direct attachment to the bony portion 
being in the form of a flattened process (the processus trian- 
gularis). 

The outer, cartilaginous portion and the inner, bony portions 
are connected by coarse connective tissue which is rich in elastic 
fibres. Fibrous tissue also fills in two or three vertical fissures 
which are found in the anterior wall of the cartilaginous canal and 
which are known as Incisure Santorini. The larger of these is 
located near the base of the tragus. They add to the mobility of 
the cartilaginous meatus and are of clinical importance inasmuch 
as abscesses of the parotid sometimes rupture spontaneously 
through them into the auditory canal. In operations on the mastoid 
process and other operations in this region which require a posterior 



SURGICAL ANATOMY. 105 

incision, the dehiscences enable the operator to turn the pinna and 
membranous canal well forward and thus gain sufficient space for 
his manipulations. 

The posterior wall of the external auditory meatus does not 
extend outward as far as the anterior, and any individual peculiari- 
ties in the orifice are generally due to variations in the size and 
position of the tragus plate. The contour of the external auditory 




Fig-. 62. — Outer aspect of the right side of the cranium of a fetus 
at birth, showing entire absence of the osseous meatus, mastoid tip, the 
drum membrane and ossicles in situ. (From Dunning's collection.) 

meatus is somewhat irregular, cross-sections showing variations of 
form and size. The anterior and inferior walls are of greater length 
than the posterior and superior on account of the oblique position 
of the tympanic membrane. The length of the posterior superior 
wall averages about 24 mm., -while that of the anterior inferior wall 
is about 35 mm. 

In the newborn the pinna shows well-developed furrows and a 
fossa between the lateral convex folds, which, in the embroyo, lie 
so close together as to form very narrow fissures only. Schwalbe 
speaks of the flower-like unfolding after birth of the heretofore 
closed aural bud. 



106 THE EXTERNAL EAR. 

Morphologically there is a lumen in the external auditory 
meatus in the newborn ; physiologically there is not, the internal, 
wedge-shaped tympanofibrous section being closed by desquamated 
epithelial cells, and the relatively wide outer funnel being filled up 
with vernix caseosa. On the removal of this external auditory 
meatus in the newborn it appears as a relatively narrow fissure flat- 
tened from above downward. At about two months of age the 
anterior and posterior walls have become differentiated. 

The osseous portion of the canal is not present at birth (Fig. 
62), but is represented by a partially formed bony ring, the annulus 
tympanicus ; meanwhile all the sutures and fissures are still wide 
open. In the adult, however, the roof of the bony meatus is formed 
by an outgrowth of the squamous process of the temporal bone. 
The anterior, inferior and lower portion of the posterior walls are 
formed from the tympanic process, while the superior and upper 
posterior sections develop from the squamous plate of the temporal 
bone. 

Some weeks after birth an increase of substance takes place on 
the tubercles at the lateral sides of the tympanic ring. The rapid 
growth of the tubercles and the simultaneous increase of substance 
in the whole tympanic ring lead to the bridge-like union between 
them, which is usually complete at the end of the first year. A gap 
or dehiscence filled with fibrous tissue remains between the lower 
periphery of the ring and the bony ridge which forms the outer 
section of the anterior and lower wall of the meatus. This gap 
usually becomes filled by bone about the third year, but it may 
persist up to the sixth year, and occasionally bony union never 
becomes complete. This dehiscence is of surgical significance, inas- 
much as pus from the auditory canal may burrow through it into 
the inferior maxillary articulation. 

The formation of the superior wall of the meatus out of the 
squamous portion of the temporal bone proceeds in such a manner 
that the squama proper above the temporal line retains its position, 
while the part situated below the temporal line gradually projects 
and assumes a horizontal position, in apposition with the anterior, 
and posterior walls. 

The relation of the walls of the adult osseous meatus is as 
follows : — 

(a) The Superior Wall. — The superior wall is directly in rela- 
tion to a layer of diploe of varying thickness, often with pneumat'ic 
cells which extend along the zygoma. Overlying the diploe is found 
the denser inner table which forms the floor of middle fossa. The 
section of bone between the superior canal wall and the middle 
fossa varies in thickness from 2 to 14 mm. 

(&) The Anterior Wall. — The superior maxillary articulation 
and a portion of the parotid gland lie directly in front of the anterior 
wall, from both of which it is separated by an exceedingly thin plate 
of bone. 

(c) The Inferior Wall. — The dense bone of the lower wall is in 
relation to the parotid gland. 



SURGICAL ANATOMY. 107 

(d) The Posterior Wall. — The posterior wall of varying thick- 
ness lies in direct relation to the mastoid cells. In its lower 
posterior portion it is in relation with the facial canal. In rare 
instances the sigmoid sinus passes close to the posterior canal wall. 

The importance surgically of the development of the bony 
external auditory meatus becomes evident when operating upon the 
mastoid process during infancy, inasmuch as the relative position 
of the mastoid antrum to the infantile auditory meatus differs from 
its anatomical relationship in the adult, and the anatomy of the 
parts in infancy must therefore be well known, when operating. 

The integument of the auditory meatus is exceedingly thin and 
delicate and lacks the resisting power observed in the integument 
of more exposed portions of the body. It is almost immovably 
attached to the structures lying underneath. The cartilaginous 
portion of the meatus contains hairs and sebaceous glands, also 
ceruminous glands, from which cerumen or ear wax is secreted. In 
the osseous portion no hair or glands are found. An exceedingly 
thin section of integument also forms the outer layer of the tym- 
panic membrane. 

The external auditory meatus receives its blood supply from 
branches oL the posterior auricular, superficial temporal and 
external maxillary arteries, the accompanying veins emptying into 
the temporal, posterior auricular and internal maxillary veins. 

The sensory nerve supply of the meatus comes from branches 
of the auricularis magnus, the auricular branch of the vagus, and 
the auriculotemporal, the motor supply coming from the seventh 
cranial. 

Lymph channels are also found which communicate with the 
posterior auricular lymphatic glands and the parotid. 



CHAPTER X. 

DISEASES OF THE EXTERNAL EAR. 

Eczema. — (a) Eczema intertrigo; (b) eczema acuta; (c) 
eczema chronica ; and other skin lesions. 

(a) ECZEMA INTERTRIGO. 

This affection is characterized by epithelial desquamation 
and serous exudate without infiltration of the deeper dermal layers. 

Etiology. — The pernicious custom of pressing or binding the 
ears of infants and young children to the side of the head by means 
of close-fitting caps or bandages is the chief cause of this disease. 
This procedure brings the posterior surface of the pinna into close 
contact with the cutaneous surface of the mastoid process, and 
thus the moisture and the normal dermal exudate collect in sufficient 
quantity to produce burning and itching, which the child attempts 
to relieve by rubbing or tearing at the binder. The superficial 
epithelium finally macerates and desquamates, leaving the raw 
surface of the deeper dermal layer exposed. Neglected children 
whose ears are rarely cleansed, whereby filth is allowed to collect 
about the ear, are prone to scratch and rub the parts until large 
surfaces become chapped, especially about and above the posterior 
attachment of the auricle. Additionally there is a copious irritating 
serous exudate which adds to the patient's discomfort. 

Unless checked by treatment, infiltration of the deeper layers 
ensues, with a resultant true eczema. 

Symptoms. — Superficial hyperemia is the first observable sign. 
This is soon followed by excessive moisture of the parts, and as 
desquamation progresses the secretion becomes copious. Burning 
and pruritus are severe, and are aggravated by the efforts of the 
child to relieve its suffering. Whenever the secretion is allowed to 
remain it becomes foul, malodorous and forms crusts which 
resemble sloughs. 

Treatment. — The denuded surfaces should be cleansed w T ith 
warm water and covered with vaselin, over which bismuth, aristol, 
or stearate of zinc may be shaken. 

If necessary, the denuded parts may be separated by layers of 
gauze ; applications of cold cream or equal parts of lanolin, vaselin 
and zinc ointment may be applied. It is essential to remove the 
primary cause of the affection, which, as a rule, is filth and the 
pernicious habit of binding the ears, or wearing tight-fitting caps 
for prolonged periods of time. 

It is important to differentiate true eczema from excoriations 
and other forms of dermatitis to which the external ear is subject. 

(108) 



DISEASES OF THE EXTERNAL EAR. 



109 



(6) ACUTE ECZEMA. 

Acute eczema of the ear is characterized by local inflammatory 
swelling and redness of the ear, upon which numerous vesicles or 
blebs appear. The disease usually appears about the external 
meatus or behind the ear, along the groove which marks the attach- 




63. — Eczema of the auricle. 



ment of the auricle to the head. From either of these points it may 
spread over the entire auricle and extend to the adjoining surfaces 
(Fig. 63). 

The secretion is usually serum, sometimes tinged with blood. 
This exudate lifts the epidermis in vesicles or sweeps it entirely 
away. 

Etiology. — A definite cause for aural eczema is not always 
determinable. The disease occurs primarily as a result of local 
irritation of the parts. The more common irritant is purulent aural 
discharge, especially when allowed to flow without the intervention 
of proper cleansing measures. Excessive cold from frostbite, or 



HO THE EXTERNAL EAR. 

the application of icebags; excessive heat from the injudicious 
employment of hot-water bags, and douches ; accidental scalds and 
sunburn ; local applications of iodoform, mercurial and other oint- 
ments, are among the local exciting causes of acute eczematous 
inflammation. 

Intertrigo has been mentioned previously as a forerunner of 
both acute and chronic eczema. Prominent among the predisposing 
causes are heredity, gout, rheumatism, leukemia and rrialas- 
similation from various causes, notably overfatigue, and unwhole- 
some or insufficient nourishment. 

Symptoms.— A sharp burning sensation, followed by pruritus, 
marks the onslaught of the disease. Whenever the external canal 
is involved the swelling may be sufficient to block off its lumen and 
produce temporary deafness and tinnitus. 

A moderate elevation of temperature is observed in young 
children. Restlessness and sleeplessness result from the pruritus, 
the latter being often noted if the surfaces are rubbed or scratched. 
As the vesicles rupture, the retained secretion covers the denuded 
surface, forming yellowish crusts, thus constituting the exudative 
stage of the disease. If the crusts are allowed to remain unmolested, 
the subsequent secretion, which accumulates underneath, becomes 
infected. This aggravates the local irritation and proportionately 
increases infiltration and thickening of the deeper layers. 

The disease may run a long or a short course. In the milder 
cases, which result from local irritation, the vesicles quickly 
rupture, or the secretion becomes absorbed and the epidermis 
exfoliates at the end of three or four days. In severe cases the 
exudate may persist for some days, then disappear; or it may 
become purulent and persist indefinitely or until checked by appro- 
priate treatment. In those who are subject to the disease elsewhere, 
or who are otherwise predisposed, an acute attack about the auricle 
may result in the development of the chronic form. The treatment 
of this disease is outlined in connection with that for chronic 
eczema. 

(c) CHRONIC ECZEMA. 

The chief characteristics of the chronic eczema are inflamma- 
tory thickening of the deeper dermal layers, persistent epithelial 
desquamation, and an aggravating pruritus. 

Etiology. — The disease results from the acute forms in all 
cases. It is usually curable, but recurrence is common. In a small 
percentage of cases the disease persists throughout life, resisting 
all forms of treatment. The employment of earspoons, hairpins or 
other mechanical means for the relief of the pruritus, and the 
removal of scales from the canal aggravate the affection and often 
result in infection of the deeper tissues and the formation of 
furuncles. It is quite common to discover patches of eczema 
squamosum in the external meatus among individuals addicted to 
the use of narcotics, especially opium. 

The disease may extend over the entire auricle, but usually it 



DISEASES OF THE EXTERNAL EAR. Hi 

is localized in and about the external meatus. The firm, red 
unyielding surface may be covered with scales or vesicles and 
traversed by fissures. 

Efforts to relieve pruritus by scratching result in abrasions, 
increased exudate and sometimes hemorrhage, and occasionally 
furuncle. 

In the chronic form the eczematous patches remain dry and 
scaly except in the fissures, or during periods of exacerbation. 
When the external auditory canal is the seat of the lesion, its lumen 
becomes much narrowed as a result, of hyperplasia. This, together 
with the copious proliferation of flaky scales, serves to occlude the 
canal and interfere somewhat with audition. 

In some individuals the scales protrude from the meatus and 
drop into the concavity of the concha or upon the clothing; or, if 
there is a pus discharge, an admixture is formed which becomes 
foul and irritating. 

Itching is Jess intense than in the acute variety; nevertheless 
it may be sufficient to cause general nervous depression. Patients 
are prone to use earspoons, hairpins, matches or finger-nails to 
relieve itching, with considerable danger of inducing dermatitis. 

Atr'ophy or destruction of the ceruminous glands is a remote 
consequence of chronic eczema of the external meatus, with a 
resultant partial or complete cessation of fluid cerumen. 

Treatment. — Successful treatment of aural eczema requires a 
preliminary, painstaking, general examination, in order to determine 
the underlying cause for the disease. 

Constitutional dyscrasias and neuroses should be corrected by 
proper attention to- diet, occupation, habits and environment, and 
also by the administration of corrective tonic remedies in the form 
of cathartics, bitter tonics, iron, arsenic, strychnine, and iodin in 
proper combination to meet the requirements of each individual 
case. Arsenic leads the list in the treatment of chronic, scaly 
eczema, and should be given in the form of Fowler's solution, 5 to 
10 drops. It should be withheld upon the first appearance of an 
acute exacerbation. For further details of general treatment the 
reader is referred tc text-books on skin diseases. 

Local Treatment of Acute Eczema. — Before considering the 
local measures to be employed it should be noted that both the 
diseased and the surrounding surfaces should be thoroughly 
cleansed, and, while water is an irritant to eczematous surfaces, it 
is often necessary to employ it for the removal of accumulated 
filth or pus. Its irritating qualities are minimized by the addition of 
table salt, a teaspoonful to a quart of water, or boric acid, SO grains 
to the quart. 

Thereafter, the surrounding integument only should be kept 
clean by washing with warm water or green soap and water. The 
wearing of bandages, coverings or tight-fitting infant caps should 
be interdicted. Purulent discharge from the meatus must receive 
proper treatment inasmuch as it excites cutaneous inflammation and 
infiltration. And here the dry form of treatment is obviously to be 



119 THE EXTERNAL EAR. 

preferred. Wiping away the secretion two or three times daily is 
usually sufficient to protect the eczematous surfaces from pus. 
Whenever the syringe is needed for the removal of retained secre- 
tion from the canal and middle ear, a warm saline or boric acid 
solution should be employed. After drying, the canal surfaces, 
unless actively vesicating, should be dusted over with calomel, 
bismuth sublimate, stearate of zinc, lycopodium or aristol. Some 
cases recover promptly without further treatment. 

For the relief of the subjective symptoms — heat, pruritus and 
tension — soothing lotions or emollients are indicated. The follow- 
ing combination, which may be varied to suit the requirements of 
the individual case, is recommended : — 

Lotio calamine : — 

R. Acidi carbolici 3j. 

Pulv. calamine 3ij. 

Pulv. zinci oxidi 3iv. 

Glycerini Sss. 

Aquas calcis 3ij. _ 

Aquae rosse q. s. ad Sviij. 

Sig. : Shake well and apply as a wet dressing. 

A soothing emollient dressing is prepared as follows : — 

R Zinci oxidi 3j. 

Morphinse acetata? gr. ij. 

Lanolini, 

Vaselini aa q. s. ad Bj. 

M. ' Sig.: Apply locally plastered upon gauze. 

The subsidence of the more acute symptoms ushers in the 
second stage of the disease, wherein the formation of yellowish 
white crusts is a prominent symptom. The crusts are to be care- 
fully removed so as not to injure the underlying tissue, and aqueous 
solutions should be avoided. It is sometimes possible to remove 
all crusts without delay by gently rubbing them with olive-oil o r 
lanolin and wiping the surface clean with dry gauze, but it may 
be necessary to apply a softening emollient for from twelve to 
twenty-four hours. For this purpose almond-oil, lanolin, or 
vaselin, applied freely and covered with gauze and a roller bandage 
is recommended. In young children especially the bandage pre- 
vents laceration from scratching with the finger-nails. 

Removal of the crusts is accomplished by means of forceps or 
blunt curette, care being taken to avoid injury to the deeper layers, 
thus aggravating the disease. In mild cases all that remains to 
effect a cure is to protect the denuded surface by applying vaselin 
or cold cream until the epidermis is re-established. Where thicken- 
ing is marked the healing process is hastened and infiltration 
reduced by daily applications of nitrate of silver solution in grad- 
ually increasing strength, from 10 to 60 grains to the ounce; or, 

H Ichthyol 3j to 3ij. 

Ung. zinci oxidi '5j. 

M. Sig.: Apply with brush or smear upon gauze and apply. 



DISEASES OF THE EXTERNAL EAR. H3 

Local Treatment of Chronic Eczema. — The treatment of the 
chronic form is attended with greater difficulties and the results 
are more uncertain in consequence of the long-continued dermatitis 
and deeper-seated hyperplasia. No attempt will here be made to 
even enumerate the numerous remedies recommended in the various 
text-books and pamphlets, many of which are of questionable value, 
but rather to outline a few that have given satisfactory results in 
the author's private and hospital practice. 

The indications for local treatment are : — 

(a) To soften and remove the scales. 

(b) To reduce the hyperplasia. 

In the chronic form more vigor may be employed in removing 
the scales, and with the distinct advantage of stimulating the circu- 
lation of the parts ; hence, the affected parts should be smeared with 
vaselin, lanolin or olive-oil and rubbed with a cotton-tipped probe 
or dry gauze until freed from all exudate. It is even permissible in 
very chronic cases with deep fissures to occasionally make vigorous 
use of green soap in order to thoroughly cleanse the parts. 

Any sign of an acute exacerbation is an indication that the 
remedies are too stimulating, and milder treatment should be sub- 
stituted for a time. 

After the parts are clean, stimulating and protective applica- 
tions should be made. The following formulae are recommended 
with the understanding that their proportions may be varied to 
meet the requirements of each individual case : — 

-E£ Oleum cadi 3j. 

Ung. zinci oxidi §j. 

M. Sig. : To be applied either as a dressing or plastered on freely, 
and covered with gauze and a bandage. 

1$ Acidi salicylici gr. xx. 

Zinci oxidi pulv 3j. 

Ung. rosae 3j. 

M. Sig.: To be applied freely. 

Nitrate of silver is advocated by many, notably Politzer. 

It should be applied in gradually increasing strength from 
5 to 20 per cent. In the' more subacute forms the ichythyol formula 
mentioned above is sufficiently stimulating. 

When feasible the local treatment should be applied daily. 
It is unwise to place sole dependence upon any one local remedy; 
hence, a change from one to another is found to hasten the healing 
process, and evidences of overstimulation of the tissues may neces- 
sitate the cessation of all treatment for a few days. For the relief 
of persistent pruritus in the external meatus, Barnhill recommends 
the following: — 

1^ Iodin (crystals), 

Carbolic acid aa gr. x. 

Rectified spirits 3j. 

M. Sig.: Paint the walls of the meatus after having removed all 
loose scales. 



114 



THE EXTERNAL EAR. 



The more obstinate the case, the more persistently must the 
treatment be applied. Relief is always attainable; permanent cure 
is sometimes impossible, and during the progress of local medica- 
tion the relative importance of general treatment must be ever kept 
in mind. 

HERPES ZOSTER. 

Ramsey Hunt, 1 in two recent publications, asserts his belief 
that herpes oticus, wherein the cutaneous- eruption is limited to the 
tympanum, external auditory canal, concha, tragus, antitragus 




Fig. 64. — Facial nerve, genicu- 
late ganglion and relations with 
the otic. 1, Facial nerve. 2, 
Geniculate. 3, Glossopharyngeal. 
4, Jacobson's nerve. 5, Small superficial petrosal. 
6, Small deep petrosal. 7, Otic ganglion. 8, 
Sympathetic ramus. 10, Middle meningeal artery. 
11, Gasserian ganglion. 12, Ophthalmic branch. 
13, Superior maxillary. 14, Inferior maxillary. 15, Sphenopalatine 
ganglion. 16, Vidian nerve. 17, Auriculotemporal nerve. (Testut's 
Anatomy. ) 

helix and antihelix, is due to herpetic inflammation (posterior 
poliomyelitis) of the geniculate ganglion, the cone-shaped area of 
distribution being termed the zoster zone of the geniculate gan- 
glion. While earlier authors have recognized the Gasserian gan- 
glion of the trifacial only, as the seat of an herpetic inflammation 
on a cranial nerve, he believes that the geniculate ganglion situated 
in the depths of the internal auditory canal at the entrance of the 
Fallopian aqueduct is the seat of this specific inflammation. 



1 On Herpetic Inflammation of the Geniculate Ganglion. A New Syn- 
drome and its Complications. Journal of Nervous and Mental Diseases, 
February, 1907. A Further Contribution to the Herpetic Inflammations of 
the Geniculate Ganglion. American Journal of Medical Sciences, August, 
1908. 



DISEASES OF THE EXTERNAL EAR. 115 

The peculiar situation of the ganglion within the confines of a 
bony canal (Fig. 64) and its immediate relation to the facial nerve 
and the auditory nerves are responsible for the characteristic com- 
plex symptoms which result. 

The pathological researches of Head and Campbell have shown 
that the disease is characterized by a specific inflammation of the 
ganglia, which become infiltrated with exudate and often with 
extravasations of blood, and, further, that the inflammatory process 
may extend to the sheath and nerve roots. Anterior or motor root 
involvement results in paralysis. Complicating paralysis is common 
in herpes oticus. Hunt* has collected 56 cases from literature and 
4 from his case book, in all of which facial palsy accompanied the 
herpetic eruption, and attributes the phenomenon to the peculiar 
location and relation of the geniculate ganglion. 

A severe type of the disease occurs when the acoustic nerve is 
also involved. In this form there are with the herpes oticus and 
facial palsy various auditory symptoms, ranging in severity from 
tinnitus aurium and diminution of hearing to the more severe forms 
of acoustic disturbance as observed in Meniere's syndrome. 

The fact that these neural complications sometimes occur in 
herpes facialis, herpes occipitalis and cervicalis is explained upon 
the theory that while the inflammation may predominate in one 
ganglion, others nearby may participate in a milder form, the zones 
here named being controlled by the Gasserian, geniculate and cervi- 
cal ganglia, which constitute together a continuous anatomical 
chain. 

The geniculate variety is classified as follows : — 

(a) Herpes oticus. 

(b) Herpes oticus with facial palsy. 

(c) Herpes oticus with facial palsy and hypo-acousis. 

(d) Herpes oticus with facial palsy and Meniere's complex. 
To complete the clinical types which occur in the region of 

the auricle, it is necessary to mention the other forms, viz., herpes 
facialis and herpes occipitocollaris, which belong respectively to 
the zones of the Gasserian and second and third cervical ganglia. 2 
Symptoms. — The initial stage is characterized by general 
malaise and slight fever. After a few hours shooting pains are 
experienced in the area involved, becoming most severe in some 
cases, and subsiding upon the appearance of the vesicles. There 
is marked swelling and redness of the skin for a period of two or 
three days preceding the appearance of the characteristic herpetic 
vesicles (Fig. 65). In herpes oticus the entire auricle may become 
red, swollen and project outward, and the external canal become 
narrowed or occluded, with consequent difficulty in cleansing or 
draining, and with diminution of hearing. The vesicles remain from 
five to eight days, then desiccate. Infiltration gradually subsides 
and recovery takes place in about two weeks. Scars remain for 

2 The phraseology of the above remarks is taken largely from Hunt's 
papers, with such interpolations as have been found necessary to complete 
the text. 



116 



THE EXTERNAL EAR. 



some months, but are rarely permanent. Paresthesia may persist 
for some time. 

In class (b) complete facial paralysis appears about the time 
of the eruption and remains from a few days to several months, 
final recovery being the rule. 

Class (c) is a type wherein disturbances of audition accompany 
the herpes in the form of tinnitus and hardness of hearing. 

Class (</) is more severe, for, in addition to facial paralysis, the 
symptoms of Meniere's disease — vertigo, nausea, vomiting, tinnitus, 
deafness, and nystagmus are observed. 




65. — Herpes oti 



(Partly schematic.) 



The relative frequency of herpes oticus is as follows : — 
In 20,000 cases (Gruber) herpes of the auricle was reported in 
5; in 65,000 cases at the Massachusetts Eye and Ear Infirmary 
herpes of the auricle was reported in 33; in 47,600 cases at the 
Manhattan Eye and Ear Hospital herpes of the auricle was reported 
in 2; in 15,000 cases at the Brooklyn Eye and Ear Hospital herpes 
of the auricle was reported in 1. 

Treatment.— The treatment is expectant, and is aimed at relief 
from pain, reduction of temperature, and prevention of deep scars. 
Asperin, gr. v, or phenacetin, gr. v, will usually control temperature 
and pain when administered internallv at intervals of four hours. 
In severe cases hypodermics of morphine may be necessary. _ The 
vesicles should be protected from accidental rupture and the irrita- 
tion of the air by pads held in place by bandages. Some relief from 
the itching and" burning will be obtained from dusting the surface 
with calomel, or stearate of zinc and boric acid. 



DISEASES OF THE EXTERNAL EAR. \\7 



PITYRIASIS CAPITIS. 

This affection occasionally extends to the external ear, and 
is best treated by rubbing into the affected areas a mixture of 
green soap and alcohol in water, combined with the general use 
of tonics. 

PSORIASIS. 

Psoriasis involving the scalp, forming distinctly marked circles, 
may extend to the posterior surface of the concha. Its circular 
appearance and tendency to bleed are usually sufficient to establish 
the diagnosis. 

Treatment. — The local lesion is usually curable for the time 
being, but it is more difficult to prevent its recurrence. There is 
probably some underlying diathetic disturbance for which appro- 
priate treatment should be instituted. Locally, the Turkish bath 
tends to reduce inflammation, loosen scales and promote absorp- 
tion. Pruritus is reduced by a lotion of carbolic acid 10 to 15 per 
cent, in glycerin, 3 or by nightly applications of chrysarobin in 
the following : — 

Chrysarobin 10 parts. 

Salicylic acid 10 parts. 

Ether 15 parts. 

Flexible collodion 100 parts. 

Sig.: Apply to skin. 

SEBORRHEA. 

Two forms of seborrhea occur upon the auricle, the oily, 
seborrhea oleosa, and the dry, seborrhea sicca. It is an exceed- 
ingly troublesome condition, giving to the skin an unclean and 
unwholesome appearance. The oily form, or seborrhea oleosa, is 
the most common and is characterized in general by a smooth, oily 
appearance and the accumulation in the creases and folds of soft, 
oily, tenacious masses (sebum), with an admixture of flakes and 
scales of a dirty yellowish color. 

In the dry form, seborrhea sicca, the skin, especially of the 
folds and creases, is covered with fine, flour-like scales or flakes. 
Pruritus is never severe and often absent, and there is no marked 
infiltration of the deeper dermal layers. 

Treatment. — In seborrhea oleosa the secretion may be effect- 
ually removed by the frequent use of soap and hot water. After 
drying the skin apply precipitated sulphur or tannic acid. 

In seborrhea sicca the scales are softened and removed by 
applying olive-oil, after which a stimulative ointment is rubbed 
in : — 

Oil sweet almonds 10 parts. 

Carbolic acid 1 part. 

Alcohol 89 parts. 

Oil ber'jfamot q. s. 

Sig.: Apply locally. 

3 Fox, Photographic Illustrations of Skin Diseases. 



118 THE EXTERNAL EAR. 



PEMPHIGUS. 



The disease is characterized by the formation of bulla? upon the 
helix or lobule. In severe cases pigmented spots remain after 
absorption. The disease runs precisely the same course as in other 
portions of the body. An acute benign form which runs a rapid 
course occurs in young children, and in hot climates a contagious 
endemic form is observed. It is a painless affection, and in uncom- 
plicated cases the treatment consists of simple protection to the 
surface by a covering of gauze. 

GANGRENE. 

Gangrene of the concha is a rare affection, seldom developing 
spontaneously, or as a result of pressure. The most common 
causes of auricular gangrene are frostbite, phlegmonous inflamma- 
tions, diabetes, measles and typhoid fever. The phlegmonous form 
is characterized by extreme redness of the surface (which does not 
disappear upon digital pressure), rise of temperature, swelling and 
tension. The enormous swelling of the concha tends to obliterate 
its normal outlines. In the circumscribed form the infiltration is 
limited to certain portions, such as the tragus or the lobule of the 
ear. In mild forms the phlegmon resolves without the formation 
of abscess or deep ulceration. When severe, the overlying integu- 
ment becomes necrotic and sloughs away, leaving a deep-seated 
ulcer, which may involve the Cartilage. Here, healing takes place 
by granulation. A rare form of gangrene has been described as 
noma. It occurs in infants and young children who are poorly 
nourished and the victims of constitutional dyscrasias. About the 
ear the gangrenous attack involves the cartilages in succession 
until a deep-seated necrotic ulcer is formed, which resists treat- 
ment and terminates fatally. 

Verhoeff 4 reports such a case occurring in an infant of five 
weeks. The disease commenced in the cartilage of the external 
auditory canal and rapidly extended. General toxemia ensued, 
death occurring on the seventeenth day. 

Autopsy. — Results showed streptococcic gangrenous ulceration 
of the auricle, middle ear and mastoid, with associated strepto- 
coccus bronchopneumonia, synovitis and croupous colitis. 

Treatment. — There is invariably a predisposing cause, which 
should be discovered and appropriate treatment instituted, in the 
form of supporting and stimulating measures. Whenever gangrene 
is fully established it is important to stimulate and sustain the 
nutrition and circulation of the surrounding tissue, and to aid in 
the separation of the necrotic slough by warm applications to the 
skin, cleansing remedies to the ulcerated surface, removal of the 
sloughing masses by cauterizing with chemical caustics, galvano- 
cautery or curette. 



Journal of the Boston Society of Medical Science, vol. v, May, 1901. 



DISEASES OF THE EXTERNAL EAR. H9 



ABSCESS OF THE AURICLE. 

Local infection with abscess formation may develop upon any 
portion of the ear from scratches, pinpricks, or piercing the lobule. 
These become infected and abscess results. They should be differ- 
entiated from perichondritis and sebaceous cysts. 



WOUNDS OF THE EXTERNAL EAR. 

The exposed position of the auricle renders it unusually sus- 
ceptible to a variety of wounds and other injuries, many of which 
result from some form of combat. Simple incised wounds of the 
skin which remain uninfected heal by primary union. Even when 
surgical division of one or more layers of the concha has been made 
the results may be equally good. Lacerated and contused wounds, 
especially when the cartilages have been injured, are more serious 
and difficult to manage, both on account of infection and injury to 
the cartilages. Completely divided segments of the concha will 
sometimes heal even when suturing has been delayed several hours 
after the injury. The so-called piercing of the lobule for ornamental 
purposes is one of the more common wounds of the external ear. 
It is often performed by the laity with no regard for modern surgi- 
cal asepsis. Sepsis results, which may extend even to the carti- 
laginous tissue or slough through to the periphery, resulting in 
fissure of the lobule. The usual treatment of wounds in general is 
applicable for these. 

ERYSIPELAS. 

From the standpoint of the otologist erysipelas assumes 
importance only when it occurs in connection with purulent otitis 
media, or following operations upon the mastoid. When it thus 
occurs it becomes a serious complication. 

Erysipelas occurring in connection with a purulent middle-ear 
inflammation, whether acute or chronic, should occasion consider- 
able anxiety, owing to the danger of middle-ear or mastoid involve- 
ment, since the erysipelatous infection is of the streptococcus type. 
Experience, however, has shown that the usual tendency of the 
disease is to spread over the integument of the face and head rather 
than toward the tympanum. 

Following a mastoid operation its appearance is to be deplored 
for the following reasons : — 

(a) The chills and extremely high temperature, which for from 
twelve to forty-eight hours precede the cutaneous flush, are most 
puzzling and always suggestive of intracranial complications. 

(b) The enfeebled state of the patient. 

(c) Contamination of the mastoid wound and consequent 
retarded healing. 

(d) Extension to the meninges (a few well-authenticated cases 
have been reported). 

(c) Removal of patient to special erysipelas wards. 



120 THE EXTERNAL EAR. 

The prodromic temperature of erysipelas, which is often 
accompanied by nausea, may easily be mistaken for lateral sinus 
infection, and erysipelas occurring as a sequela to mastoidectomy is 
apparently more common than in ordinary surgical operations. 
The similarity of infection may explain the phenomenon in part. 
This disease should not be confounded with iodin or iodoform 
dermatitis, which it somewhat resembles, the latter being more 
superficial and without high temperature. 

Special Treatment. — The mastoid wound should be packed 
with moist bichlorid or Burrough's solution dressings, to be 
changed every two hours. The wound and middle ear may be 
douched with warm saline solution whenever accumulations of pus 
or masses of slough are found. A wet dressing of Burrough's 
mixture applied to the cutaneous lesion relieves the sensation of 
burning. Ichthyol in 25 per cent, solution serves the same purpose. 
The borders of the lesion may be seared with silver nitrate in solid 
stick, but there is no known specific for this disease, which usually 
runs its course unchecked by any form of medication. Hypodermic 
injections of the Hiss leucocyte extract (see page 99) are favored 
by Dwyer and others. 

DISEASES OF THE AURICULAR PERICHONDRIUM. 
Perichondritis. 

Perichondritis of the cartilages of the ear is an inflammation 
of the perichondrium, with tumefaction of the superficial tissues 
and subperichondrial serous exudate. 

Etiology. — Wounds, contusions and bruises of the aural car- 
tilages and extension from furunculosis or other infectious inflam- 
mation. It does not occur idiopathically. 

Symptoms. — Following an incision, blow, bruise or contusion 
of the auricular cartilage, or furunculosis of the external canal, the 
anterior surface of the concha becomes tumefied, with cutaneous 
redness, the tumefaction gradually extending until the normal lines 
of the concavity of the auricle become obliterated. The lobule, 
being free from cartilage, remains normal. If the swelling extends 
into the external meatus, the hearing becomes impaired tem- 
porarily. 

The swelling is chiefly the result of subperichondrial effusion, 
whereby the perichondrium becomes detached over considerable 
areas, with proportionate loss of nutrition" of the underlying car- - 
tilage. The exudate is always serous, and only becomes purulent 
after receiving infection from without. 

Fluctuation marks the appearance of the exudate. Absorption 
may gradually take place without permanent injury or deformity. 

If infection supervenes and the exudate becomes purulent, rup- 
ture may ensue, with fistulous formation, or further detachment of 
the perichondrium may ensue and necrosis of the cartilage 
result, leaving marked external deformity- The disease resembles 
othematomata, from which it may be differentiated by aspirating a 



DISEASES OF THE EXTERNAL EAR. 121 

few drops, of the retained exudate, which, in the latter, is invariably 
hemorrhagic. 

The chronic form sometimes exists for weeks or months, ter- 
minating in hypertrophy and deformities of the cartilage, which 
may involve the external meatus. 

Treatment. — The early treatment should consist in the employ- 
ment of antiphlogistic measures — cold applications, local blood- 
letting, and the placing of the patient at rest after free purgation. 
A small Leiter coil may be applied to the affected area for a period 
not to exceed twenty-four hours. In some cases applications of 
heat seem to be more effective. 

These measures are employed to prevent subperichondrial 
effusion, and if attended. by failure it becomes necessary to remove 
the exudate in order to circumvent possible necrosis of the cartilage 
and subsequent deformity of the auricle. At first it is permissible 
to aspirate the retained secretion. This procedure should be fol- 
lowed by the application of pressure pads, so placed upon the oppo- 
site sides of the auricle that a roller bandage will hold the detached 
perichondrium in firm contact with the periosteum. In severe 
cases, especially when the secretion has become purulent, it is a 
wiser procedure to make a free incision through all the tissues down 
to the cartilage, and rely upon the open method of treatment, under 
strict asepsis. 

By this means the operator is enabled to obtain exact knowl- 
edge of the extent of the diseased area, and to effectually meet the 
requirements of the individual case. The resultant deformities of 
the auricle are sometimes remediable by plastic surgery. 



OTHEMATOMATA. 

Othematoma, or hematoma auris, is an effusion of blood be- 
tween the perichondrium and cartilage of the auricle, and usually 
occurs as a result of direct violence. It is quite common in the 
insane, where it seems to develop spontaneously. Even here the 
possibility of self-inflicted mutilation and accidental injury by 
attendants in enforcing restraint may account for many cases of so- 
called "insane ichor." Blows, especially such as are received in 
boxing and prizefighting combats, are accountable for the majority 
of cases. In sporting circles the othematous auricle is dubbed "the 
cauliflower ear" on account of its resemblance to that vegetable 
( Fig. 66). It is more common in the left ear, which is more acces- 
sible to the opponent's right hand. In one of the author's cases, 
that of a prizefighter, both ears were involved. 

Symptoms. — Following an injury the effusion develops rapidly 
by separating the perichondrium from the anterior cartilaginous 
surface. 

The tumefaction is tense, with less sense of fluctuation than is 
usual in fluid sacs, and tends to obliterate the normal outlines of the 
concha. The cutaneous surface is deep red, with a bluish tint. 
The tumors are smaller when of spontaneous origin. Audition is 



122 



THE EXTERNAL EAR. 



unaffected except when the tumor encroaches upon the lumen of 
the external meatus. 

Pain is never severe and consists of a disagreeable sensation of 
tension, heat and itching - . In the idiopathic form there is no pain. 

Treatment. — The form of treatment to be followed depends 
upon the variety and extent of the disease. Small tumors of 
probable spontaneous origin may disappear by absorption, with 
no treatment except warm applications. Compresses or massage 




Fig-. 66. — Othematoma of the auricle. 



tend to excite renewed hemorrhage from the already weakened 
blood-vessels. 

Should the tumor increase in size after two or three weeks, it 
should be treated surgically in exactly the same manner as those of 
traumatic origin. 

In the treatment of large hematomata the indications are to 
reduce the hemic contents of the tumor and re-establish the circu- 
lation of the parts, and to conserve the conformity of the auricle. 
Whenever it is possible to institute treatment at the very outset, 
an icebag should be applied over the ear after placing pads of 
gauze or absorbent cotton before and behind the ear in such a 
manner that pressure will be minimized. In some instances heat 
is preferable to cold. Aspiration is convenient during this stage, to 



DISEASES OF THE EXTERNAL EAR. 123 

be followed by moderate compression of the parts; but recurrence 
of the fluid is the rule. If the tumor shows no tendency to sub- 
side after a day or two, it should be classed as operative. 

When the injury is severe and causes fracture or bruising of 
the cartilage or laceration of the soft tissues, infection becomes 
imminent and prompt surgical interference is imperative. In cases 
of long standing the clot is usually infected; hence, the treatment 
should be surgical. 

Multiple puncture, styptic injections, electrolysis, and setons 
are at the best merely makeshifts and almost invariably convey 
infection. 

A clean surgical incision possesses the following advantage: 
(a) asepsis; (b) complete evacuation of the tumor contents; (c) 
a wide open area which reveals any pus, granulations, necrosed 
areas of cartilage or soft tissue, and permits their complete removal; 
(d) minimizes the danger of subsequent destruction of cartilage 
and of deformity of the auricle. 

Permanent thickening of the auricle is common. Marked 
deformity ensues in cases where destruction of the cartilage has 
been extensive. Here plastic surgery may be employed to cover 
denuded areas, to correct deformity, and to maintain the patency of 
the external meatus. The procedure necessarily varies in different 
cases, and too much must not be promised in the way of cosmetic 
results. 



CHAPTER XI. 

DISEASES OF THE EXTERNAL EAR. 
(Continued.) 



OTITIS CIRCUMSCRIPTA FOLLICULARIS 
(Furunculosis of the External Meatus). 

Furunculosis of the external auditory canal is an acute cir- 
cumscribed inflammatory process involving the corium and sub- 
cutaneous tissues of the cartilaginous portion of the external canal. 
It is usually a purulent condition surrounding a central slough or 
core. 

It occurs (a) as a primary or idiopathic process ; (b) secondary 
to purulent otitis media ; (c) as a result of such general diseases as 
diabetes, anemia and syphilis; (d) trophic disturbances; (c) bac- 
terial invasion. 

Etiology. — There are authorities who affirm the cause to be 
bacteria which enter through the hair follicles or sudoriferous 
glands ; nevertheless the most common cause is direct infection 
through abrasions of the dermal layer. It is well known that the 
skin of the external auditory canal lacks certain elements which 
give it much resisting power in other parts of the body. Under 
these conditions abrasions, scratches or contusions are extremely 
liable to follow any form of manipulation, such as rough usage of 
the cotton-tipped probe in the hands of the careless or unskilled, 
which act is liable to cause abrasions of the canal with hemor- 
rhage. 

This is illustrated in the ease with which the laity may, by 
using various' unsterilized appliances for the purpose either of 
removing cerumen, or scales, or in attempting to relieve pruritus, 
inoculate an otherwise healthy surface and cause furunculosis. 
The affection is more common in women than in men, probably on 
account of the employment of the ever-ready hairpin to clean the 
canal and relieve itching. A patient's efforts to remove pus from 
the auditory canal also often result in lacerations, and the pus 
becomes the infecting factor. 

Inflammatory and suppurative processes in the walls of the 
external auditory canal, while usually provoked by mechanical 
means, result also from escharotic or corrosive agents. The 
milder forms of the disease usually subside without forming pus. 
The severe types, which are characterized by actual infection, and 
deep-seated inflammation, gradually develop into abscesses or 
furuncles. 

Symptoms. — The subjective symptoms are variable during the 

early stages. An indefinite sensation of soreness and fulness is the 

initial symptom. This is aggravated by any form of manipulation 

of the auricle. Pain soon becomes severe and continuous, remain- 

(124) 



DISEASES OF THE EXTERNAL EAR.. 125 

ing the most troublesome symptom throughout the course of the 
disease. It is greatly intensified by the slightest pressure, and 
tends to radiate to the jaw. The pain of furunculosis shows a tend- 
ency to nocturnal exacerbations and morning remissions. It is 
believed by some observers that furunculosis of the canal occa- 
sionally assumes an epidemic character. The severity of the 
attack increases proportionately with the distance of the inflam- 
matory focus from the orifice of the auditory canal. Pain is intensi- 
fied by mastication, inasmuch as the movements of the jaw affect 
the inner wall of the external auditory meatus. 

Deafness is not common and when present is due to occlusion 




Fig. 67. — Furuncle of the external meatus viewed through the 
speculum. The illustration shows three points of bulging coming into 
view as the speculum is pushed into the swollen and edematous tissues. 

of the canal, either by the infiltration or by the accumulation of pus 
and epithelial debris in the canal lumen. 

The Objective Symptoms. — A circumscribed inflammatory area 
appears at some point along the auditory canal, and the localized 
swelling diminishes or completely occludes the lumen. Its exact 
location comes into view as the tip of the speculum gradually 
imping-es upon the walls of the meatus (Fig. 67). Several inflam- 
matory foci are sometimes found. Occasionally the abscess will 
project from the external auricular orifice, the neighboring region 
participating in the redness and swelling. The lymph glands under- 
neath the lobule and in front of the tragus are often swollen and 
painful upon pressure. At times the infiltration and abscess forma- 
tion become so extensive that the superficial tissues external to 
the auricular attachment become enormously swollen. The author 
observed several such cases where the concha stood out at right 
angles to the head, generally giving the appearance of advanced 



126 THE EXTERNAL EAR. 

mastoiditis (Fig. 124) with external swelling and periostitis. 
Careful local examination cleared up the diagnosis. Constitutional 
disturbances are slight. There may be a slight elevation of tempera- 
ture, with headache and diminished appetite. 

Course of the Disease. — The disease is limited to the external 
auditory canal and the tissues in the immediate vicinity, and usually 
subsides after a few days of suppuration. A\ nen allowed to rupture 
spontaneously, relapses are common, owing to autoinfection, thus 
giving the disease the appearance of a chronic affection. 

Early incision of the abscess shortens the course of the disease, 
and hastens the separation of the central slough or core. The sur- 
rounding infiltration and swelling subsides promptly with the 
evacuation and local treatment of the abscess. 

Diagnosis. — In simple cases it is not difficult to determine the 
nature of the affection, a simple inspection through an aural specu- 
lum (Fig. 67) sufficing. Whenever the abscess is located at the 
orifice of the meatus the speculum may be dispensed with. If 
multiple abscesses are suspected a speculum of small calibre should 
be gentlv shoved into the deeper portions of the canal, in order to 
locate all suspected points. Every manipulation is attended with 
pain, and especially the impact of the speculum and the touch of 
the probe. By slowly inserting a medium-sized speculum, under 
good illumination, the bulging cutaneous wall of the abscess will 
often come into full view. 

Differential Diagnosis. — The disease is differentiated from the 
following : — 

(a) Exostosis of the auditory canal, by its density, painless- 
ness, and absence of inflammatory appearance. 

(b) Atheromata, by their sluggish growth and painless 
character. 

(r) Polypi, by their granular surfaces and spongy feel under 
probe. 

(d) Mastoiditis ; when the tumefaction is extensive and the 
pus cavity large, with postauricular swelling, the case simulates 
mastoiditis and is difficult to differentiate. 

On three occasions the author has been summoned to perform 
a mastoid operation, to find only a postauricular distention caused 
by a furuncle, which was entirely relieved by free incision through 
the canal wall. In mastoiditis there is no tumefaction in the outer 
portion of the canal ; movement of the auricle causes no pain ; there 
is usually a history of profuse aural discharge, preceded by some 
form of infectious process in the nose and nasopharynx, and pain 
upon direct pressure over the mastoid area. 

(c) Parotid abscess; which may cause the wall of the canal 
to bulge upward, simulating furuncular infiltration. Here there is 
marked swelling over the parotid gland, and the amount of pus is 
entirely out of proportion to that of furunculosis. 

Treatment. — During the early inflammatory stage, previous to 
the formation of abscess, abortive forms of treatment should be 
adopted. After thoroughly cleansing the canal of all debris of 



DISEASES OF THE EXTERNAL EAR. 



127 



every nature and ascertaining the location of the inflammation, a 
fairly large tampon or cone of cotton dipped in either a 50 per 
cent, boroglycerid solution, or, preferably, a solution of carbolic 
acid, 12 per cent, in glycerin, is introduced and allowed to remain 
in the canal from twelve to twenty-four hours. Should the tampon 
produce undue pain the patient is directed to remove it at any time, 
and to follow its removal by a hot saline or bichlorid of mercury 
douche. Ordinarily, patients bear the tampon with but little com- 
plaint. During this period a hot-water bag, continuously applied 
to the ear, gives much comfort to the patient. Applications of 
iodin, nitrate of silver, massage or electricity have been advocated, 
but are of doubtful efficiency. 

Local bloodletting offers some relief to tension and may exert 
an abortive influence. If attempted the incision should be made 



1 m ■** 






i t 


* ■ 




\w£m 






\ 


.*. 


Ghf&-< 












V; ^f 


wB 


v- 


k 


W^" 







Fig. 68. — Lateral view of the external meatus showing furuncle in 
posterior wall. The furuncle knife is inserted and about to freely open 
the abscess. 



directly into the infected tissues and be of sufficient depth to serve 
at the same time as a channel for the escape of pus whenever it may 
form. 

The internal administration of analgesics is rarely neces- 
sary, although occasionally the pain is sufficient to require them. 
The majority of cases terminate in abscess formation, for the 
relief of which free incision is the only speedy and effective 
method (Fig. 68). If a carbolized tampon has been employed 
the meatus will need no further preparation for operation; other- 
wise, such a tampon should be introduced and allowed to remain 
in contact with the abscess for twenty minutes. A slight degree 
of anesthesia is then produced. A sharp furuncle bistoury (Fig. 
52) and a quick thrust give the least pain. The patient's head 
should be firmly held and the field of operation brightly illumined. 
The point of the knife is then introduced to the inner border of 
the abscess and plunged 'to the bone, severing the entire abscess 
sac as the blade is pulled outward toward the meatus. Curet- 
ment of the abscess cavity will hasten the healing process. A 
small strip of gauze introduced into the abscess cavity serves for 
drainage and prevents the wound from closing too soon. A warm 



128 THE EXTERNAL EAR. 

saline douche every two hours removes accumulations of pus and 
keeps the parts clean. At the daily visit the abscess cavity 
should be irrigated and accumulations removed from the canal. 
In a space so confined it is difficult to remove the infected area 
with sufficient thoroughness to avoid the possible danger of auto- 
infeCtion, whereby recurrences take place. 

OTITIS EXTERNA DIFFUSA. 

Synonym. — Diffuse inflammation of the external auditory 
meatus. 

Etiology. — The disease is usually caused by traumatism, 
foreign bodies, lacerations during their removal, or from the 
entrance into the canal of caustics or irritant fluids, and infections 
from within the tympanum or from external sources. More rarely 
it results from eczema, herpes zoster, pemphigus, erysipelas, small- 
pox, measles, scarlet fever, gonorrhea, syphilis, lupus, and vegetable 
parasites. 

The disease is characterized by diffuse inflammation of the 
auditory canal. It may involve the superficial cutaneous surfaces 
only and result in desquamation ; or penetrate into the deeper 
tissues, causing thereby extreme redness, swelling, and terminating 
in suppuration. 

Symptoms. — Patients complain chiefly of pain, tinnitus and 
deafness. The pain varies with the severity of the attack, and is 
due to swelling and tension of the parts. It is aggravated by the 
movements of the jaw. Deafness and tinnitus result from occlusion 
of the canal, inflammation of the drum membrane, or accumula- 
tions of exudate. In the simpler forms the walls of the canal and 
the membrana tympani become covered with desquamations, which 
may fill the entire canal. In the phlegmonous variety the canal 
walls become tender, swollen and narrowed to such an extent that 
examination of the deeper portions is difficult. When visible, the 
tympanic membrane appears inflamed and thickened, with indis- 
tinct outlines, and, in rare instances, perforations. Ecchymoses 
sometimes develop in the walls of the canal and after a few days 
rupture takes place, with a discharge of serum or seropurulent 
exudate, containing pathogenic organisms. This discharge is ex- 
ceedingly tenacious, and, as it becomes dry, it tends to exfoliate in 
masses, leaving inflamed, angry-looking, moist areas, which obliter- 
ate the normal landmarks. 

Diagnosis. — The diagnosis is rarely difficult. Bright illumina- 
tion and the judicious use of the probe are usually sufficient, 
although the exact determination of the condition of the lower 
segment of the auditory canal and tympanum may be impossible 
on account of the swelling and tenderness. 

The course and duration of the disease depends largely upon 
its mode of origin. The existence of grave constitutional disease is 
indicative of a protracted course. Simple acute cases usually 
terminate in recovery in from three to ten days. Prolonged 



DISEASES OF THE EXTERNAL EAR. 129 

phlegmonous inflammations, with recurrence of abscess formations, 
sometimes finally result in periostitis or even exostosis of the bony- 
walls, with atresia of the canal. 

Prognosis. — In simple cases, unattended by grave infection, 
recovery takes place in a few days. In rare instances the middle 
ear becomes extensively diseased as a sequela to otitis externa 
diffusa, and the inflammation has been known to extend frcmi the 
superior and posterior canal walls directly t l o the cells of the 
mastoid process, and finally to the meninges, the latter complica- 
tion being more common in young children. 

Treatment. — While this disease often requires more extensive 
local treatment and prolonged personal attention, the treatment 
corresponds in a general way to that given for circumscribed otitis 
externa. When of bacterial origin, carbolized tampons should be 
introduced, and, if well borne, allowed to remain from twelve to 
twenty-four hours. During the stage of secretion a hot saline 
douche every two hours will effectually remove the products with- 
out irritating the inflamed surfaces. After drying the surface, 
powdered stearate of zinc with boric acid, equal parts, dusted 
over the diseased area, tends to promote healing. 

Whenever a stimulating medicament is needed, a solution of 
nitrate of silver gr. xx to %], or 25 per cent, solution of argyrol will 
answer the purpose. When associated with eczema or other cuta- 
neous affections, or constitutional dyscrasias, the scope of medica- 
tion must embrace these disorders. 



OTOMYCOSIS 
(Otitic Externa Fungoides). 

In the preceding paragraph, devoted to diffuse external otitis, 
the desquamative type of inflammation is considered. Another 
type, less common, is due to deposits of various forms of fungi 
upon the walls of the external canal and usually is termed otomy- 
cosis. These types are of vegetable' origin (molds), and appear in 
a great variety of forms, of which the aspergillus niger, fumigatus 
and flavescens are the chief. The source and mode of entrance are 
rarely determinable, but there is reliable clinical evidence that the 
spores will not germinate in a normally healthy external meatus, 
but require some form of exudate upon which to grow. Certain 
types, like the mycelium, depend upon moisture; others require 
a dry exudate for their propagation. The seat of predilection 
is the inner third of the auditory canal and the membrana tympani. 
Extensive invasions of either type may take place without 
producing any subjective symptoms whatever, but their pres- 
ence usually excites a sensation of irritation and itching, for the 
relief of which the patient scratches his ear and produces the 
excoriation of the meatal orifice noted in this condition. Deafness 
and tinnitus occur only in cases where extensive diffuse infiltration 
narrows the lumen of the canal. In rare instances the pain is 
severe and persistent until relieved by removal of the fungi. 

9 



130 THE EXTERNAL EAR. 

The fungi spread over the surface of the inner third of 
the canal, and often the membrana tympani (myringomycosis), in 
the form of dirty white, yellowish, or blackhead deposits. The 
elevated surface of the mass appears dirty, uneven, but velvety in 
appearance, and is commonly mixed with cerumen, discharge 
or scales. It often requires a microscopic examination to confirm 
the diagnosis. The surface involvement may be extensive, or 
limited to one or more masses upon a circumscribed area. The 
parasites cling closely to the affected parts, and their removal is 
sometimes difficult to accomplish, leaving the surface more or less 
reddened and thickened. A permanent redness points to recurrence. 
Cutaneous desquamation, the employment of oils in the external 
canal, occupation, unsanitary environment and moisture, or dis- 
charge in the canal, are believed to be the chief predisposing etio- 
logical factors in otomycosis. The mere existence of a purulent 
exudate does not necessarily predispose to the disease. Otomycosis 
affects men more commonly than women, and children seem to be 
exempt. Observations bear evidence that the parasites reach their 
maturity within from five to seven days. If perforation of the drum 
membrane is present, it is quite possible for the parasites to enter 
and develop in the tympanic cavity, and cases have been reported 
in which they invaded the mastoid cells. 

Treatment. — The treatment of otomycosis is directed toward 
the removal of the parasites and prevention of recurrence. A few 
drops of boric acid gr. xx in alcohol §j instilled into the meatus 
several times daily has proved most useful for their destruction as 
well as for the prevention of recurrence. Whenever the deposit is 
extensive, preliminary washing with the syringe or thorough 
removal by means of a curet may be necessary. If the growths 
persistently recur, a bichlorid of mercury douche followed by 
instillations of 95 per cent, alcohol will eventually effect a cure. 

OTITIS EXTERNA KERATOSA 
(Otitis Externa Parasitica). 

This is a rare form of otitis, wherein a white pseudomembrane 
is observed, which is usually situated along the posterior wall of 
the bony meatus (Bezold). The fibrinous deposit is easily removed 
from the bony canal as well as the tympanum, although consider- 
able pain attends its removal. 

IMPACTED CERUMEN. 

The normal secretion of the ceruminous glands, which are 
located chiefly in the cartilaginous portion of the external meatus, 
is light yellow, semifluid in character, and under healthy condi- 
tions tends gradually to approach the external orifice, where it 
becomes removed in the ordinary course of daily washing. 

The proximity of the intermaxillary articulation, the capsular 
ligament of which stands in close relation to the tragus, is supposed 
to be an important factor in moving the cerumen toward the outer 



DISEASES OF THE EXTERNAL EAR. 131 

orifice of the meatus, inasmuch as with each motion of the joint, 
whether in talking or mastication, there is an impingement upon 
the canal. 

Etiology. — Several etiological factors, acting either singly or 
in combination, enter into the causation of retained ceruminous 
plugs. 

1. Anomalies and Obstructive Lesions of the Canal. — Retention 
of cerumen sometimes occurs in canals which are of extremely 
small calibre at certain points throughout ; in those that are con- 
genially tortuous, or when the walls are the seat of exostoses or 
hyperostoses. 

2. Foreign Bodies. — Foreign substances which are allowed to 
remain in the canal serve as a nucleus to which cerumen adheres. 
Of these cotton pledgets carelessly left in the canal, either from 
attempts to remove debris or while worn for protection, are the 
most common. Beads, seeds and particles of dirt, coarse dust and 
splinters occasionally serve the same purpose. 

3. Diseases of the Middle Ear and External Meatus. — Eczema 
and other cutaneous diseases, circumscribed and diffuse external 
otitis, and purulent otitis media, both by extensive exfoliations and 
by modifying the character of the ceruminous exudate, are prolific 
causative agents. The frequency of its association with chronic 
catarrhal otitis media suggests a possible concurrent alteration in 
the ceruminous glands whereby the quantity of secretion is dimin- 
ished from lack of fluid elements. Cholesteatomata which have 
exfoliated from the middle ear sometimes form a portion of the 
mass. Hypersecretion of cerumen, while rare, sometimes occurs, 
and variations in the amount secreted are wide, even within normal 
limits. 

4. Mechanical Causes. — Aside from foreign bodies, the agglu- 
tination and retention of cerumen is facilitated by wrong methods 
of cleansing the ears. Irritant solutions, portions of which are 
allowed to remain in the canal, thereby causing superficial inflam- 
mation and exfoliations, overstimulate the ceruminous glands or 
cause superficial dermatitis and exfoliation. In the ordinary clean- 
ing of the canal, by wiping with cotton-tipped probe or twisted 
corner of a handkerchief or washcloth or earspoon, masses of 
cerumen are easily pushed deeper in, where they . remain and 
increase in size. 

Pathology. — Cerumen masses are usually of complex formation, 
having, in addition to the ceruminous exudate, variable admixtures 
of sebaceous matter, flakes of epidermis, and fragments of hair, 
spores and central foreign bodies. The color of the plugs varies 
from light yellow to reddish black, very old plugs often having a 
glistening appearance from the presence of cholesterin crystals. 
Prolonged contact of large masses of impacted cerumen probably 
excites more or less extensive desquamative inflammation of the 
walls, osteitis and perforation of the membrana tympani. 

Symptomatology. — So long as the ceruminous plugs do not 
attain sufficient size to completely obstruct the calibre of the canal, 



132 



THE EXTERNAL EAR. 



all subjective symptoms are absent. An extremely small channel 
seems to be sufficient to admit sound waves and maintain the hear- 
ing function practically unimpaired. A change of position of the 
mass, due to violent jarring of the body, or to the movements of 
mastication, whereby the canal becomes totally occluded, will 
produce deafness. The same result often ensues after bathing, and 
is explainable as follows : The bather, who has a cerumen plug 
which nearly fills the calibre of the canal, gets water into the ear, 
and sufficient moisture is absorbed to cause the mass to swell and 
close the entire lumen of the canal. Complete occlusion is imme- 
diately followed by a sensation of fulness in the ear, deafness, tinni- 
tus, and often vertigo. Autophony is a common symptom. Upon 
inspection during the earlier stages, the accumulated cerumen may 
be seen covering certain portions of the meatal walls, either as 
sticky masses, or in the form of flakes, crusts, or wads. As these 
increase in size by accretions, they tend to extend in either direc- 
tion until the entire canal is occluded with possible pressure upon 
the drum membrane. The tinnitus is variable in its intensity, but 
is at times so loud and troublesome as to become the sole cause for 
seeking relief. When perforations exist, all symptoms are aggra- 
vated, and trigeminal neuralgia, facial paralysis, and blepharospasm 
have occurred. Pain rarely ensues, although at times, owing to 
pressure, neuralgic pains may be felt, not necessarily localized, but 
radiating in various directions. 

Among the reflex symptoms cough is most prominent. It may 
become so severe as to induce congestion in the upper respiratory 
tract. 

Complete blocking of the canal necessarily perverts the func- 
tion of audition, and in nervous subjects considerable mental dis- 
turbance may accompany the condition. Vertigo, nausea, and 
epileptiform seizures have been known to result from impaction of 
cerumen in the auditory canal. Impaction in canals which have 
long been the seat of a purulent process may lead to serious conse- 
quences on account of the obstruction to the outflow of discharge. 

Diagnosis. — Careful inspection of the auditory canal is the 
only method by which a positive diagnosis may be made. It must 
be differentiated from cholesteatomata, blood-clots, foreign bodies, 
inspissated pus, and a variety of admixtures of ephithelium, mucus, 
spores and foreign bodies. 

Prognosis. — The outcome is less easily determined, as hyper- 
secretion of cerumen is frequently associated with other forms of 
disease. The mere cerumen mass in an otherwise healthy ear is 
never a grave condition. It is unwise to predict that a return of 
hearing will follow the removal of the cerumen mass, inasmuch as 
deafness from other causes may have pre-existed. Whenever the 
loss of hearing is sudden and entirely due to occlusion, the prognosis 
as to hearing is invariably good. Recurrence is the rule, and 
patients should be so informed, and advised to return at intervals 
of about six months in order to prevent a repetition of the impac- 
tion. It is wise to record the aerial conduction sound before remov- 



DISEASES OF THE EXTERNAL EAR. 133 

ing cerumen, in order to circumvent any contention as to loss of 
hearing which the patient may subsequently make. In one instance, 
in the author's experience, a clinic patient threatened legal pro- 
ceedings, claiming that the removal of masses of cerumen had 
resulted in great diminution of hearing. The record of the hearing 
distance previously made easily proved the patient's error. 

Localized masses smearing the posterosuperior wall of the 
canal are usually indicative of a purulent process within the tym- 




Fig. 69. — Syringing the ear for the removal of cerumen. The patient's 
clothing is protected by the bib (Fig. 7), augmented by a towel tucked 
between his neck and collar. The patient holds the pus basin for the 
return flow, which leaves the surgeon free to manipulate the syringe and 
hold the ear in proper position. 

panic cavity, and their removal may be followed by renewal of the 
discharge. 

Treatment. — Obviously the treatment should he directed to the 
removal of the mass. When the masses are small and not densely 
impacted, a few syringefuls of warm water will be sufficient to 
effect their removal. Hard plugs, densely impacted, are difficult 
to remove at the first sitting, and, inasmuch as a short delay is not a 
detriment to the patient, it is wise to desist for a day, in the mean- 
time directing the patient to instill at short intervals either warm 



134 THE EXTERNAL EAR. 

saline solution, common salt 5j to sterile water Oj or a solution 
of sodium bicarbonate 5j to giv of sterile water. Instillations of 
peroxid of hydrogen are more eti'ective, and the author has never 
observed any harmful results from its use. The stream from the 
syringe (Fig. 69) should be directed to the borders of the cerumen 
mass as the most likely place for the solution to get behind and 
force it outward. Considerable force may be expended upon the 
current without damage to the parts. It is sometimes impossible 
by means of the syringe to throw the solution behind the hardened 
mass, and it becomes necessary to supplement its action by means 
of a small curet or probe, and make a groove between the cerumen 
and the canal wall through which the water may be forced, always 
pointing the syringe toward the groove. In rare instances cerumen 
resists all efforts at removal with water ; hence, it becomes neces- 
sary to extract it piece by piece, with forceps and curet. Following 
the removal of cerumen the auditory canal should be carefully dried 
and inspected, meanwhile noting any injury to the canal walls or 
drumhead. The surfaces may then be thoroughly smeared with 
liquid vaselin containing menthol in the proportion of 10 grains 
to the ounce, and a small tampon of cotton inserted for a day. The 
patient should be directed to return in a day or two, at which time 
the canal should be thoroughly touched with alcohol in order to 
destroy any vegetable fungi, and such further applications as the 
condition "of the parts may require. Unless absolutely necessary 
the introduction of forceps, spoons and curets should be avoided 
in the removal of cerumen masses. Finally, before dismissing the 
patient, the hearing distance should again be tested for purposes of 
comparison. 

FOREIGN BODIES IN THE EAR. 

On account of the exposed location of the ear and its open 
meatus, a variety of foreign bodies find lodgment in the auditory 
canal, and. occasionally, penetrate the deeper structures. 

Etiology, (a) In Children. — There seems to be a natural tend- 
ency among young children to introduce small objects, either into 
the mouth, nose or ear. These accidents are usually self-inflicted, 
but occasionally they practise upon each other. The more common 
substances thus found in the meatus are pebbles, beads, bits of 
wood, glass objects, buttons, gravel, pasty substances, peas, beans, 
and other seeds. 

They are likewise subject to the accidental impaction of gun 
wads, explosive materials, bullets, etc., and to the entry of animate 
objects, bedbugs, roaches, houseflies, ticks, maggots, etc. 

(b) In Adults. — In adults the causes are : i. The habit (usually 
pernicious) of wearing cotton in the ears, pledgets of which are 
carelessly forgotten, or pushed deeper into the canal by additional 
ones. 2. FfTorts to remove cerumen, scales or pus, by means of 
hairpins, toothpicks, matches, and twigs, whereby portions are lost 
in the canal. 3. Animate objects, bedbugs, roaches, moths, flies, 
ticks, worms and maggots. 4. Explosives, gun wads, bullets, 



DISEASES OF THE EXTERNAL EAR. 135 

portions of rockets, cloth and fibre. 5. Foreign bodies incident to 
occupations, seeds, chips, scales of iron or steel, coal, etc. 6. 
Otoliths. 

Symptoms. — Unless producing distressing symptoms, a foreign 
body may remain undisturbed for an indeterminate period, during 
which it becomes encased in an admixture of cerumen and epithe- 
lial scales. Here the symptoms are similar to those already 
described under impacted cerumen. Those which enter under force 
and lacerate the tissues invariably cause sufficient hemorrhage, 
pain and discomfort to cause the patient to seek relief. 

Explosives and knife or stiletto tips are prone to wound the 
deeper tissues, with very serious results. 

Young children either inform their attendants, or the accident 
becomes known through inflammatory reaction or hemorrhage. 
Insects, when alive, produce agonizing, nerve-racking sensations by 
their crawling or clawing efforts to move about the canal. 

The larger seeds like beans and peas become troublesome as 
a result of absorption of moisture, which causes them to swell and 
occlude the canal. Pain is always more severe when these objects 
lie against or lacerate the drum membrane. 

The results are more harmful in ears which are the seat of 
purulent discharge, since by retarding the flow of pus, or by con- 
tamination with animate objects serious complications may arise. 

Ballenger 1 calls attention to the ravages of the Texas screw- 
worm fly, which possesses a sawing movement which enables it to 
penetrate bone, and recalls Mackenzie's reports of cases where they 
penetrated the cranial cavity, causing death by meningitis. 

Diagnosis. — The diagnosis is simple and easy in recent cases 
where no laceration, swelling, or hemorrhage has taken place, inas- 
much as under strong reflected light the body may be both seen and 
touched with a probe. 

This is the only reliable and proper method to follow. Unfor- 
tunately, these patients are seldom seen by the otologist at this 
stage, consulting him only after the walls of the canal have been 
lacerated, or inflamed as a result of unskilled efforts to extract the 
offending mass. Having already suffered considerable pain and dis- 
comfort, the patient, if a child or a hypersensitive adult, approaches 
in extreme trepidation; hence, the examination should be deferred 
for a few minutes, and his confidence inspired by reassuring state- 
ments Rather than examine an unruly patient under force, with 
probable damage to the soft tissues, it is wiser to administer a 
general anesthetic, which permits both thorough examination and 
a painless and safe removal. 

Treatment of Foreign Bodies in the Ear. Insects. — First deter- 
mine positively by visual examination whether the insect still 
remains in the canal. Nervous patients are prone to complain of 
the crawling sensation long after the insect has escaped, and are 
sometimes on the "border line" of insanity. The author has the 



1 Diseases of the Nose, Throat and Ear, p. 601. 



136 



THE EXTERNAL EAR. 



record of a woman who stoutly and persistently maintained that 
she had a bedbug in her ear, and would not be convinced to the 
contrary until, in desperation, a bedbug was procured and inserted 
into the canal without her knowledge. It was then withdrawn and 
exhibited to her with convincing effect. 

If alive, the insect should be drowned or otherwise killed before 
attempting its removal, on account of its power to cling to the 
surface. Immersion in oil usually suffices, but in case it fails a few 
drops of chloroform diluted one-half will complete their destruction, 




Fig. 70. — A method to be employed for removing buttons from the ex- 
ternal meatus whenever the eye or eyelet can be seen by the surgeon. 



after which they are easily removed, either with the syringe or 
forceps — preferably the former. 

Inanimate Bodies in the External Canal.— The body should be 
removed by the safest possible method which may be suited to the 
individual case. Of these the syringe, employed in exactly the same 
manner as for impacted cerumen (Fig. 69), is the safest and most 
effective. Zaufel successfully removed the object with the syringe 
in 92 out of 109 cases, about 90 per cent. 

The invariable rule should be to attempt removal with the 
syringe before resorting to any other method. In a large percent- 
age of cases the syringe alone will successfully clear the canal of 
the obstruction. As already stated a careful preliminary examina- 
tion through a speculum, with a bright illumination, should be made, 



DISEASES OF THE EXTERNAL EAR. 



137 



at which time all the lacerations and bruises, and hemorrhages, 
whether incident to the inward passage of the body or as a result 
of clumsy unskilled attempts to remove the object, may be seen. 

If the tissues about the meatus are greatly swollen and painful 
and there are no indications of deep-seated injury, it is wiser to 
delay removal for a day or two until these symptoms subside. 
Rest, hourly warm douches, and depletion by wet cupping are 
helpful adjuvants. It now becomes possible to determine the form 
and nature of the object, its exact location, and whether it is firmly 




Fig. 71. — Removal of oval object (bean) from the auditory meatus 
with forceps. This method should be employed only in the hands of 
skilled operators, on account of the danger of pushing the foreign body 
deeper into the canal, wounding the membrana tympani, etc. 



impacted in the lumen of the canal. If reasonable persistence in 
syringing fails to remove the object, the plan of procedure should 
be as follows: The object may be located in a manner which 
permits the operator to grasp it firmly with the forceps or hook into 
some eyelet or angle without danger of forcing it deeper into the 
canal. In this class are found wads of cotton, paper or cloth, the 
eyelets or thread holes of buttons (Fig. 70), the edges of metals, 
sticks, buttons and similar substances. After securing a firm hold, 
traction should be made directly toward the meatal orifice until the 
object is extracted. During this time the head should be steadied 
by an assistant. The removal of objects with smooth oval surfaces, 



138 TI1E EXTERNAL EAR. 

like beans, peas, beads, etc., is obviously a more difficult procedure. 
Here the employment of forceps is contraindicated unless in skilled 
hands (Fig. 71), inasmuch as in applying the jaws there is danger 
of forcing the object into the deeper portions of the canal, always 
an unfortunate occurrence on account of the added difficulties in 
removal incident to a location beyond the narrowed juncture of the 
osseous and cartilaginous portions of the canal. The agglutination 
method has been recommended in this type, and consists in gluing 
the end of a small piece of tape, or a small camel's hair brush to 
the surface of the object, and, after it becomes firmly fixed, to make 
sufficient traction to pull out the foreign body. 

Another procedure is to gently slide a small hook between the 
canal wall and the object, and by a slight corkscrew motion imbed 
the tenaculum into the mass and thus withdraw it. Ouires's foreign 
body extractor (Fig. 72) is also available here. It sometimes hap- 
pens that the first insertion of the hook merely pries up one side of 
the object, in which event it should be reinserted upon the opposite 
side and the object thus removed. 




Quires's foreign body extractor. 



In removing denser objects, glass, metals, etc., it may be neces- 
sary to insert a small curet or spoon, even at the expense of slight 
laceration, in order to obtain sufficient hold to remove them. In 
young children and many adults it is quite impossible to remove 
the more deeply imbedded foreign objects except under general 
anesthesia ; hence, it is advised, and its employment greatly simpli- 
fies the operation, but should in no wise lessen the importance of 
observing all precautions against injuries to the drum membrane 
and canal wall. 

There are rare instances wherein large, dense objects become 
deeply imbedded in the bony or cartilaginous walls, when it is 
impossible to extract the object except by posterior incision and 
detachment of the canal from the bone in the manner followed in 
the removal of exostoses of the canal, or the radical operation. 

Foreign Bodies in the Middle Ear, Eustachian Tube and Other 
Parts of the Temporal Bone. — These are usually bullets or other 
projectiles, or the broken tips of swords, knives or stilettos. Unless 
a projecting portion can be grasped with strong forceps and the 
entire object removed by traction a surgical operation should be 
performed without delay, and under all the precautions required by 
modern surgery. The preliminary steps are precisely those followed 
in removing an exostosis from the bony canal by the postauricular 
route. By this means it becomes comparatively easy to chisel or 
pry out the mass. It may, however, become necessary to chisel 



DISEASES OF THE EXTERNAL EAR. 139 

away a portion of the bone from the canal wall at the transition of 
the auditory canal into the tympanic cavity, or even to open the 
antrum or labyrinth in case the foreign body has been lodged in 
these regions. The requirements subsequent to such operative 
procedure would be closure of the Avound and the maintenance of 
the membranous canal in position by suitable packing. 

Small bodies in the tympanic orifice of the Eustachian tube 
may sometimes be withdrawn by forceps through an open drum 
membrane, and, if protruding from the faucial opening, removed 
with properly curved forceps, aided by a rhinoscopic mirror. 
Operators have succeeded in dislodging Eustachian obstructions by 
Politzerization, first removing a window from the drum membrane. 

Syphilis, diphtheritic and croupous inflammation, and lupus of 
the external ear form a part of Part II, Chapters XXIX, XXX, 
XXXI and XXXII. 

ATRESIA (STRICTURE) OF THE EXTERNAL 
AUDITORY CANAL. 

Etiology. — Constrictions of the auditory canal are either 
osseous, fibrous or in- the form of new growths, and are due to 
inflammatory disease of the walls, purulent otitis media, traumatism 
and congenital deformity. The osseous form (exostosis) is de- 
scribed in Chapter XIII, Fig. ^7. Those due to neoplasms of the 
auricle are also outlined in Chapter XIII. 

Inflammatory affections (eczema, dermatitis, furuncle, peri- 
chondritis, otitis externa diffusa) in severe form may result in 
fibrous thickening of the deeper layers of the canal and constriction 
of its lumen. Circumscribed thickening of the skin, with cicatricial 
bands, or circular constrictions are produced both by prolonged 
otorrhea and traumatism. Similar results follow the ulceration of 
lupus, tuberculosis, and syphilis. Marked atresia is prone to follow 
a radical mastoid operation in which the operator has failed to 
divide the membranous canal by making the usual flap. 

Treatment. — Various simple procedures have been devised to 
overcome contraction and adhesion of the soft tissues, the chief of 
which are vulcanized and soft-rubber tubes, tampons, sponge tents, 
caustics, etc. Unfortunately, they usually fail to produce permanent 
benefit. In the majority of cases a single cicatricial band which has 
resulted from traumatism will disappear under the pressure of a 
hard-rubber tube. The only positive and permanent relief is 
derived from detaching the concha by posterior incision and enter- 
ing the auditory canal by way of the posterior wall in the same 
manner as in the radical operation. When the stricture is confined 
to the cartilaginous meatus it may require a division of the mem- 
branous canal and the formation of a skin flap similar to those which 
form a part of the radical mastoid operation. Whenever atresia 
occurs in conjunction with and as a result of prolonged intra- 
tympanic suppuration, it is advisable to perform the radical opera- 
tion, and by so doing effect a cure both of the purulent disease of 
the ear and constriction of the canal. Tn those cases where the 



140 



THE EXTERNAL EAR. 



walls of the cartilaginous meatus are simply collapsed, with no 
cicatrices, or tumors, the introduction of tubes for the purpose of 
improving the hearing is without avail except so long as they 
remain in situ. 

Electrolysis has its advocates, and has been employed with 
success, in simple cases unaccompanied by suppuration, by inserting 
the needle of the negative pole into various portions of the fibrous 
tissue, and the positive sponge electrode elsewhere upon the body. 
Treatment should be given every other day unless too much 
reaction results, each seance lasting ten to twenty minutes, with a 
current strength of 8 to 30 milliamperes. 

CARIES OF THE OSSEOUS EXTERNAL AUDITORY CANAL. 

Carious areas in the bony portion of the external canal wall are 
usually of serious import, and occur with sufficient frequency to 
merit a brief outline of its etiology and treatment. 




Fig. 73. — Carious mastoid process. Removed from a child 14 years old. 
(Author's case.) 



Etiology. — (a) Purulent otitis media, in which the inner por- 
tion of the osseous canal and outer attic walls become necrosed. 

(&) Purulent mastoiditis. The majority of all cases of caries 
in this location result from purulent mastoiditis, with every evidence 
of a primary attack of unusual severity, and rapid extension of 
infection from the mastoid cells through the canal wall. Large 
sequestra of necrosed bone sometimes come away through fistulous 
openings in the canal wall, or remain exposed for indefinite periods. 
Fig. 73 is a photograph about the natural size of a necrosed mastoid 
process, including a portion of the posterior canal wall in a young 
child who had suffered with an offensive discharge from the ear for 
about three years. The author removed it by making the usual 
mastoid incision, followed by a radical mastoid operation, which 
proved entirely successful. 

(c) Malignant neoplasms and infections. Primary carcinoma 
of the ear usually springs from the floor of the external canal, and 
erosion of the bone is one of the early symptoms. Tuberculous and 
specific ulceration may also result in necrosis of the canal wall. 



DISEASES OF THE EXTERNAL EAR. !4l 

(d) The author has seen a single case of caries which could not 
be traced to the above causes. It was a small circumscribed spot 
about the size of a millet seed, upon the floor of the canal. The 
exposed area was dry and there was no history of purulent otitis 
media, injury or cutaneous disease, nor evidence of syphilis, tuber- 
culosis or malignancy. It was scraped away with a curet and has 
never returned. 

Treatment. — A fistulous opening along the posterior canal wall, 
which communicates with the mastoid process, is invariably indica- 
tive of extensive necrosis of the mastoid cells, which in many 
instances extends through the inner table, exposing the meninges 
or lateral sinus to infection. From every standpoint a mastoid 
operation is the only treatment worthy of consideration, and usually 
the radical operation is essential in order to reach the limitations 
of the necrotic process. 

Small sequestra in other partions of the wall, which do not 
communicate with the deeper bony structures, may be removed 
through the external meatus by means of the curet and forceps, 
after dislodging granulations and polypi. 

Whenever the necrosis results from malignant or infectious 
diseases, the treatment should be governed by the requirements 
in the individual case, descriptions of which will be found under 
their appropriate headings. 



HEMORRHAGE OF THE EXTERNAL AUDITORY CANAL. 

Hemorrhage of the walls of the auditory canal occurs in three 
varieties : — 

(a) Spontaneous. — This is a rare phenomenon in which the out- 
flow is of a serosanguineous nature, without abrasion of the skin or 
periodicity. 

(b) Vicarious. — Periodical hemorrhage from the external 
meatus sometimes occurs in young females as a perversion of the 
menstrual function. 

(c) Traumatic. — Hemorrhage from traumatism may arise from 
deep-seated injuries to the temporal bone, either from direct or 
indirect violence. Severe injuries sometimes result in fatal hemor- 
rhage. 

In rendering a diagnosis the possibility of malingering must 
be eliminated. 



CHAPTER XII. 



DISEASES OF THE EXTERNAL EAR. 

(Continued.) 



MALFORMATIONS AND ANOMALIES OF THE 
EXTERNAL EAR. 



Malformations and defects of the auricle 
forms from slight deviations in size and shape 



occur in various 
of the individual 
parts to almost complete absence of 
the entire organ. Reduplication of 
one or more of its parts and super- 
numerary auricle (polyotia) also de- 
mand consideration. Any marked 
deviation from the normal is very 
noticeable on account of the prom- 
inent situation of the auricle in the 
general contour of the face and the 
head. The auricle, in man., has little 
to do with the hearing function ; 
therefore, its defects do not produce 
impairment of audition unless the 
deformity occludes the entrance of 
the external meatus and prevents 
the free access of sound waves into 
the auditory canal. But deafness is 
common in malformed ears, and it 
is usually due to a coexisting mal- 
development, or entire absence of 
the external auditory canal, the mid- 
dle ear, or the labyrinth. 

The treatment is largely de- 
signed for cosmetic purposes and is 
surgical. 

Malformations and defects in 
the external ear are not necessarily 
indicative of perverted mentality, 
notwithstanding the large proportion of such abnormalities among 
individuals who are mentally impaired. They are usually unilateral, 
and occasionally accompanied by maldevelopment in the bones of 
the corresponding side of the face. 

Some are due to the absence of cartilage, while in others there 
is entire absence of the auricular appendage, barring certain nodules 
or tags found in its usual location. The cartilage may be unduly 
thin or thick, or of irregular shape, or the normal folds, depressions 
and creases may be obliterated or abnormal, with corresponding 
alteration in the contour of the helix and antihelix. The angle of 
(142) 




Fig. 74. — Projecting ear, with 
abnormal droop or lop. There 
is also redundant cartilage and 
deformity of the helix. 



DISEASES OF THE EXTERNAL EAR. 



143 



attachment of the auricle, especially when its upper portion is 
unduly large, is responsible for many ill-formed appearing- ears. 
The so-called "lop ear" (Fig. 74), whether congenital or acquired, 
is of this type, and occasionally the entire upper portion of the 
pinna droops downward and forward in a flabby, ill-shaped mass. 

Occasionally the defect takes the form of abnormal enlarge- 
ment or diminution of the concha, lobule, or entire auricle. One of 
the author's patients has a diminutive auricle of infantile propor- 
tions which has never grown since birth, and he is now 42 years of 
age. The helix is overhanging but otherwise the auricle is well 
formed (Fig. 75). There is no external auditory canal, but the 
Eustachian tube is normal, patulous, and is susceptible to inflation. 
Audition, however, is absent. 



Fig. 75. — Diminutive auricle, with absence of external meatus. The 
patient has a normal and patulous Eustachian tube capable of inflation, but 
no hearing-. 



MALFORMATIONS AND ANOMALIES OF THE AURICLE. 

(a) The Auricle. — The auricle as a whole may be over- 
developed (macrotia), there may be a marked difference in the size 
and contour of a person's auricles (asymmetry), or the point of 
attachment to the head may be abnormal (heterotopy). 

Goldstein 1 measured a large number of auricles and found 
(Fig. 76) that the long axis measuring from the tip of the lobule to 
the highest point of the helix, a, b, should not exceed 7y 2 cm. (3 
inches), and the width measured from the inner curve of the tragus, 
transversely to the outer edge of the helix, c, d, should not exceed 
3 cm. (lj.ii inches ). 

The angle of insertion of the auricle, described by Frigario as 
the auriculotemporal angle, in normal ears is acute; hence, an 
auricle which projects at a right or obtuse angle from the head 
(Fig. 74) occupies an anomalous position. 



The Laryngoscope, October, 1908, p. 826. 



144 



THE EXTERNAL EAR. 



Microtia. — The term microtia is usually employed to define a 
class of congenital defects in which the auricle has no definite form, 
with absence of certain portions, perversion of the normal outlines, 
or almost entire absence of the appendage. 

Strictly speaking, any under-sized ear, whether perfect or 
imperfect in outline, is classed as microtic (Fig. 75). Almost 
invariably microtia is associated with maldevelopment of other 
portions of the auditory apparatus, chiefly, absence of the external 





Fig. 76.— Diagrammatic represen- 
tation of the normal measurements 
of the auricle. A to B = iy 2 cm.; 
C to D = 3 cm. (After Goldstein.) 



Fig. 77. — The satyr ear. 



auditory canal. The Eustachian tube is usually intact and patulous, 
but the labyrinth may be defective. 

The defect may be bilateral or unilateral, and coexisting defect 
of the contour of the face and perverted mentality are not 
uncommon. 

(b) The Helix and Antihelix. — Minor variations in the scroll- 
like formation of the helix are common, and consist of abrupt 
angles or other irregularity of outlines, as is observed in the satyr 
ear (Fig. 77) or in a lack of development or overdevelopment of 
the part. 

The upper portion is the usual seat of faulty development, and 
here the helix is oftener absent than overdeveloped. Cases of 



DISEASES OF THE EXTERNAL EAR. 



145 



enormous overdevelopment of the helix have been reported (Fig. 
78). The anthelix shares with the helix in some of its deformities, 
and is susceptible to individual variations, chiefly that of undue 
projection and division into two or three crura. It is sometimes 
absent altogether. 

(c) The Lobule.— The lobule is subject to a variety of malfor- 
mations in size and in shape. Of these the enlarged bulbous lobule, 
common to the negro races, the thin elongated, and the flat fan- 
shaped are the chief types. The lobule is sometimes absent 
altogether, and it is occasionally bifid ; the latter condition usually 





Fig. 78. — Redundancy and deformity of the helix. 
(Goldstein. With permission.) 



is a result of wearing heavy earrings, or results from the sudden 
tearing of earrings through the soft tissues (Fig. 79). In one case 
observed by the author (Fig. 80) a large horny excrescence pro- 
jected from the tip of the lobule. 

(d) The Tragus. — Deformities of the tragus are rare. It is 
sometimes much enlarged with a backward flare that partially or 
wholly closes the external meatus. Anomolous cartilaginous pro- 
jections are occasionally observed. A supernumerary tragus, usually 
rudimentary, is sometimes observed on the surface near the ear 
(Fig. 81). ' 

(c) Fistula Congenita Auris (Fig. 82). — The author has 
observed two cases of this anomaly, in both of which there was a 
small fistulous opening in front of the tragus. They are blind 
canals, from 3 to 6 mm. in depth, having no connection with the 



146 



THE EXTERNAL EAR, 



middle ear, and secrete a thick serous exudate. Similar cases were 
iirst described by Heysinger, and are believed to be due to the 
incomplete closure of the first or second branchial cleft. 

(/) Supernumerary Auricles (Polyotia). — Multiple auricles are 
extremely rare, and are usually without definite form, although a 
few which were well formed have been reported. The presence of 
cartilage in a supernumerary growth about the face or along the 
sternocleidomastoid muscle may rightly be considered a super- 
numerary auricle. 

They are essentially cutaneous growths and may be either 
unilateral or bilateral. 

Treatment. — Microtic auricles constitute a class of deformities 
that, unfortunately, cannot usually be 
corrected. In some instances slight im- 
provement in shape may be effected by 
appropriate plastic surgery. 

An artificial pinna is less conspicuous 
and, therefore, preferable to the more 
exaggerated and unsightly appendages 
made of nodules of cartilage and skin 
tabs. 

It is useless to attempt any operation 
to form an artificial external auditory 
canal, but, if a rudimentary canal is pres- 
ent and the hearing tests are positive re- 
garding the conducting and perceptive 
function of the middle ear and labyrinth, 
it may be feasible to enlarge the meatus. 
The Stacke operation, modified if neces- 
sary to suit the individual case, and com- 
pleted by a Koerner or a Panse flap, per- 
mits a wide opening in the outer portion 
of the meatus. Prolonged after-treat- 
ment by packing with gauze is necessary 
to insure success. 

Macrotia. — To reduce an abnormally 
large auricle for cosmetic purposes, it is 
necessary to resect some portion of the 
redundant cartilage. Several procedures 
have been recommended and employed in 
which a triangular section is resected, the base of which forms an 
arc from some portion of the free border of the helix. (Figs. 83, 84 
and 85 illustrate the steps of an operation commonly performed). 
The primary incision should transfix the entire auricle from a 
to b (Fig. 83), the line of incision to be varied according to the 
degree of correction required. The upper segment is then slid 
downward, overlapping the lower, to a varying point, c, d (Fig. 84), 
which line represents the section to be resected. It is sometimes 
preferable to resect from the lower segment. 

An additional section, n, z, d (Fig. 85), is then removed, in 




Fig. 79.— Bifid lobule. 
Showing line for incision 
a-b and a-c to be fol- 
lowed in performing a 
plastic operation to over- 
come the deformity. 



DISEASES OF THE EXTERNAL EAR. 



147 



order to permit perfect coaptation of the parts and without deform- 
ity of the free border. Goldstein 2 has ingeniously devised a plan 
of operation wherein he raises a large curvilinear flap of cartilage 
and slides it forward upon the remaining cartilage, from all of 
which the pericondrium has been separated. The opposing flaps 
are then held one upon the other by strong catgut sutures, and the 
cutaneous opening closed. 

Projecting or "Lop-ear." — Two general types of auricles par- 
ticipate in this deformity, (a) Those without redundant cartilage. 
(&) Those with redundant cartilage. 




Fig. 80. — Large horny excrescence projecting from lobule. (Author's case.) 



(a) The deformity may be overcome without resecting any 
cartilage. A simple technique is that of denuding a sufficient 
surface both upon the dorsum of the auricle and the corresponding 
side of the head (Fig. 86), and suturing the borders to each other. 
Duel 3 has devised an ingenious but rather complicated operation 
whereby the auricle is drawn backward and upward by a strong 
skin flap, which is passed underneath a cutaneous loop raised from 
the scalp near the posterior auricular angle and anchored upon the 
denuded surface. 

(b) An operation devised by Goldstein contemplates both 
reduction of redundant cartilage and correction of malposition of 
the auricle, the section of cartilage to be reduced subcutaneously 



2 Transactions of the American Larvngnlogical, Rhinological and Otolog- 
ical Society, 1908. 

3 Transactions of the American Laryngological, Rhinological and Otolog- 
ical Society, 1908, p. 104. 



148 



THE EXTERNAL EAR. 



through incisions made primarily for the purpose of correcting the 
malposition. 

A curvilinear incision is made upon the posterior surface of 
the pinna, commencing at about its upper point of attachment (Fig. 




p-jg. 81. — Supernumerary tragus. 




82. — Fistula congenita auris. 



87), a, b. The flap is then reflected backward over the upper 
mastoid region. A second incision is then carried through the 
cartilage (Fig. 88, e, /). The perichondrium is then separated from 



Piff. 84. 



Fig. 85. 




Figs. 83, 84, 85. — Usual technique for reducing macrotia. (From Goldstein, 
Laryngoscope, October, 1908. With permission.) 

the anterior surface of the auricle and the cartilage flap c, d (Fig. 
89) is made to overlap the contiguous cartilage, where it is retained 
by mattress sutures (Fig. 90). 



DISEASES OF THE EXTERNAL EAR. 



149 



After removing the redundancy of the original skin flap a, b, it 
is replaced and united (Fig. 90). The wrinkling of the skin upon 
the anterior surface of the auricle disappears in a short time. This 
operation is applicable for the correction of other forms of enlarge- 
ment of the auricle by adopting the necessary modifications in each 
individual case. 

The line of incision is then dusted with aristol, covered with 
flexible collodion and gauze. Loose gauze is now carefully placed 
upon the pinna in such a manner that the bandage will hold it in a 
normal position. 

The cosmetic results, in cases where good judgment has pre- 
vailed in all the steps of the operation, are most gratifying. 

The Lobule. — The lobule is vascular and 
contains no cartilage ; therefore, plastic opera- 
tions to correct those which are unduly wide 
or elongated are feasible. 

Resect a wedge-shaped section of sufficient 
size to leave a normal-sized lobule after the 
denuded surfaces have been approximated. A 
bifid lobule is repaired by denuding the integu- 
ment (Fig. 79) a, b and a, c, and coapting the 
wound margins with fine-silk or horsehair 
sutures. 

Supernumerary Tragus, Cartilaginous Pro- 
jections and Fistula Congenita Auris. — Resect 
the supernumerary tragus together with any 
cartilage by means of an elliptical skin incision, 
and close the wound by suture. 

A cartilaginous projection is unsightly, 
and should be removed by resection of the 
entire projection. A small area of skin from 
the anterior surface may be retained for the 
purpose of covering the denuded base of the growth. 

A fistula congenita auris is easily removed by excising the 
entire blind canal and coapting the raw edges with sutures. 

Polyotia. — The removal of supernumerary auricles and rudiment- 
ary tabs is accomplished by plastic operations, in which all carti- 
lage should be resected. A flap of integument is first dissected 
from the surface of the appendage, sufficiently large to cover the 
denuded space from which the growth is excised. This flap is then 
carefully stitched to the borders of the wound. By so doing the 
resulting scar is almost nil. 

Operations involving the auricular cartilage should always be 
attended with due regard for asepsis. The blood supply is meagre, 
and, when once infected at any point, the whole cartilage is prone 
to succumb, with disastrous results, in which the auricle shrivels 
into an unsightly mass. 




Fig. 86.— Usual in- 
cisions for correcting 
deformities of "lop 
ear." 



150 THE EXTERNAL EAR. 

Fig. 88 



Fig. 87 






i 




F - e 


Ar / 




7 


* 


I ' -i K M 






i- b 


\? 




iF 






Fig. 89 







f^Bjf— ex 


c- 


/ : 

" LJJ'JbEN * f 

■LI 






. u ■ 




d-' 




• 







Fig. 90 












C- j 


/ 


- - 

■ 


Ik " a 



Figs. 87, 88, 89, 90. — Serve to illustrate the steps of operation for project- 
ing auricle. (From Goldstein, Laryngoscope. With permission.) 



CHAPTER XIII. 

DISEASES OF THE EXTERNAL EAR. 

(Continued.) 

NEOPLASMS OF THE AURICLE. 
1. Benign Growths. 2. Malignant Growths. ^ 

Papillomata. — Benign epithelial excrescences usually assume 
the form of ordinary papillomata, or common warts. Ordinary 
papillomata appearing on the auricle are similar to those observed 
in other portions of the body and require the same treatment. 
They are invariably small, being seldom larger than a small pea. 

Dense horny offshoots with broad bases spring from the rim 
of the helix or the tip of the lobule. In one such case (Fig. 80) 
seen by the author the entire lobule had become elongated and 
hard and hoof-like in density. The mass was about three-fourths 
of an inch in length and one-half in diameter, and blunt at the 
distal extremity. These ossifications are rare and occur among 
uncleanly and ill-nourished people — at least, such was the environ- 
ment of the author's case. 

Treatment. — Common papillomata or warts should be clipped 
with scissors, close to the base of attachment, and the cut surface 
seared with fuming nitric acid or fused chromic acid. 

Horn}'- growths require complete removal by excision with the 
scalpel. 

Fibromata; Keloid. — Of the deeper-seated tumors the fibroma 
type is more common, the lobule being the usual seat, although 
it may appear on any portion of the auricle. The negro race is 
especially prone to the development of both fibromatous and keloid 
growths. 

Fibroma develops in the connective tissue and results from 
mechanical irritation. The numerous accidents and injuries asso- 
ciated with the wearing of earrings suffice to produce enough 
irritation to cause fibromata to develop. Old mastoid and other 
wounds about the ear become the seat of development in the same 
racial proportion. 

In size the fibroma varies from a millet seed to that of a hen's 
cp;^, often becoming sufficiently large to partially or wholly occlude 
the external meatus. The surfaces are usually smooth and hard, 
with few if any nodules, and are rarely pedunculated. Recurrence 
after removal is common. 

Prognosis. — The prognosis, so far as life is concerned, is good, 
there being no positive evidence, even in unoperated cases, of 
alterations in structure or degeneration into malignant type. 
Tendency to recur, even after repeated and most thorough removal, 
constitutes the chief obstacle to a favorable outcome. 

(151) 



152 



THE EXTERNAL EAR. 



Treatment. — The treatment consists in the thorough removal 
of the entire mass, under the strictest asepsis, the incisions to be 
carried well into healthy tissue. Much pains should be taken in 
coaptating the opposing surfaces and in stitching closely, with the 
minimum irritation, by means of fine catgut sutures. When located 
upon the auricle a V-shaped incision, including the tumor, followed 
by careful approximation of the cut surfaces, eventuates in but 
little deformity, when the growth is of moderate size. Small 
growths, unattended with marked disfigurement, should not be 
subjected to operation. 




Fig. 91. — Postauricular sebaceous cyst. (Author's case.) 



Sebaceous Cysts. — Sebaceous cysts (atheromata) are invaria- 
bly the same wherever they may occur, the causative factor being 
the inflammatory closure of a normally open mouth of a sebaceous 
gland, with the inevitable accumulation of normal sebaceous 
secretion. 

About the ear the favorite site is the lobule and the space 
posterior thereto, at the aural junction with the temporal bone (Fig. 

The sebaceous cyst is not painful even upon pressure, and it is 
slightly movable and soft to the touch. Spontaneous rupture, 
through the skin, from overdistention, sometimes takes place, in 
which event the sac becomes partially emptied of sebaceous con- 
tents, followed by closure. 

Treatment. — Applying modern surgical precautions, the opera- 



DISEASES OF THE EXTERNAL EAR. 153 

tion requires a free incision through the skin, avoiding, if possible, 
the sac wall, and careful dissection and removal of the cyst wall. 
This may require the vigorous application of the curet. 

After cleansing and suturing a pressure pad is placed over the 
tumor site and a suitable bandage applied. In a majority of 
patients local anesthesia suffices. 

Cystomata. — This form of tumor, when occurring in the concha, 
is a non-traumatic collection of fluid within the soft tissues of the 
auricle, without involving the perichondrium. They are sacculated, 
contain no clots, and usually contain serum only. Occasionally a 
small surface of cartilage will be found exposed at the inner wall 
of the cyst. They are usually found upon the anterior surface, often 




Fig. 92. — Extensive congenital angioma of the auricle, the side of the 
face and the head (side view). Over a considerable portion of the central 
area the cutaneous surface is bluish red. On palpation the mass feels like 
an aggregation of distended blood-vessels. 

assuming considerable proportions. The pain is slight, merely a 
sensation of heat, and no tenderness upon pressure. They usually 
appear quite suddenly, and, unless injured or unduly manipulated, 
there is but little tendency to increase in size after the first appear- 
ance. But little is known as to their causation. 

Treatment consists in complete evacuation. This was formerly 
accomplished by means of aspiration. Later developments have 
shown that free incision, complete evacuation of the contents, and 
the application of sufficient pressure to hold the surfaces together 
until healing takes place, with perhaps a slight wick drain during 
the first two or three days, will usually effect a cure with but little 
danger of recurrence. 

Angiomata. — Two varieties of vascular neoplasms are observed 
upon the auricle: 1, the simple, which usually occurs in the form 
of small bright-red or bluish patches of various sizes, with little 
elevation or swelling, and located chiefly upon the anterior surfaces. 



154 



THE EXTERNAL EAR. 



2, the cavernous, which are large pulsating tumors, commonly in- 
volving the adjacent structures, notably the jaw and face. The cases 
observed by the author have all been congenital. Others have 
reported cases resulting from injury or frostbite. 

Jungken 1 reports a fatal hemorrhage resulting from a congeni- 
tal nevus. The deformity attendant upon these growths is so 
marked and disfiguring that the otologist is usually consulted as 
to the best means for promptly reducing the growth and otherwise 
improving the general appearance. In one of the author's cases 
similar to that reported by Chimary, and described as cirsoid 
aneurism, 2 the entire lobule was enormously enlarged from birth, 




Fig. 93. — Same as Figure 92 (front view). The illustration shows 
that the auricle is completely detached from the temporal bone and hangs 
loosely as a part of the tumor mass. The face is asymmetrical. 



the tumor involving the entire region of the squamous and mastoid 
portions of the temporal bone, and extending forward over the face 
to a point about midway from the ramus of the jaw to the point of 
the chin. It was deep-seated, semi-fluctuating, with bright-red 
surfaces (Fig. 92). 

The auricle had become completely detached from its bony 
attachment and sagged an inch or more with the tumor mass and 
produced an ugly deformity (Fig. 93). This case was considered 
inoperable. 

Treatment. — For simple birthmarks without extensive venous 
enlargement, electrolysis or repeated galvanocautery applications 
in the form of linear cuts may be depended upon to effect a cure, 
but not without some scarring. Multiple puncture has been recom- 



1 Schwartze's Ohrenheilkunde, p. 77. 

2 Archiv fur Ohrenheilkunde, vol. viii, p. 63. 



DISEASES OF THE EXTERNAL EAR. 155 

mended. Cavernous tumors, unless sufficiently limited in area to 
be operable by excision, may be destroyed by means of Esmarch's 
method of silk threads passed deeply through the tumor, having 
been previously immersed in the tinct. ferri perchloridi solution. 
Several of these are introduced at one time, the ends being allowed 
to project from the point of entry and exit, and the whole tumor 
surface protected by a stearate dressing until healing is complete. 
Various forms of styptic injections, administered with the hope of 
coagulating the tumor contents, have not proven successful and 
are attended with more or less danger arising from the dislodg- 
ment of small portions of any resultant clot in the form of emboli. 
Excision is applicable in appropriate cases, numerous ligatures 
being employed through the base in order to control hemorrhage. 
Whenever the entire auricle is the seat of cavernous angioma, but 
little improvement may be hoped for from any form of treatment. 

Deposits of lime or uric acid salts found about the upper 
half of the concha in the form of hard oval lumps, sometimes as 
large as a pea, are not infrequently found. These usually occur in 
gouty individuals. 

MALIGNANT TUMORS OF THE AURICLE AND EXTERNAL 
MEATUS. 

Malignant tumors of the auricle and external auditory canal 
are not common. They may occur in these parts either primarily 
or as offshoots, by continuity, from those located elsewhere. 
Sarcoma is rarely primary. 

The neoplasm may originate in any portion of the auricle and 
subsequently extend to the meatus, or the order may be reversed. 
The cases of epithelioma observed by the author have invariably 
originated in the external meatus, and gradually extended through- 
out the pinna, and at the same time they have slowly migrated 
inward through the tympanum, mastoid process, labyrinth, and 
finally have entered the cranial cavity, with fatal results. 3 Of the 
two varieties — epithelioma and sarcoma — the former is much more 
common. 

Epitheliomata. — Epitheliomatous neoplasms originate in the 
form of small, shiny, tough nodules, superficially located, the nature 
of which may be long unsuspected until ulceration and degenera- 
tion ensue. They also become a local manifestation of more 
generalized carcinoma. 

The cancerous proliferation extends throughout the entire 
tympanum and accessory spaces, usually reaching the cranial 
cavity, where it produces a fatal issue. Occasionally the carcino- 
matous development in the ear is secondary, and reaches this loca- 
tion either by way of the tubal canal or from the cranial or nasal 
cavities. Tt rarely occurs in the young, the larger proportion of 
cases recorded being between the ages of forty and sixty years. 

3 According to Toyn1>ce, carcinoma usually develops in the mucous 

membrane of the tympanic cavity. 



156 THE EXTERNAL EAR. 

The condition is associated with severe pain, early and persistent, 
and a profuse offensive and bloody discharge, often containing 
small particles of bone. In the later stages, vertigo, severe tinnitus, 
deafness and even facial paralysis may appear. The ulcerated 
surfaces are covered with exuberant granulations, elevated above 
the surrounding surfaces, and associated with redness and swelling 
in the adjacent tissues. In the later stages the ulcerations are 
covered with a sanious exudate. Death usually occurs as the result 
of exhaustion or extension to vital organs. The duration is from 
one to two years, seldom longer, although one of eight years and 
another of twenty-one years have been recorded. Previous to the 
development of pain, the symptoms are those of intense irritation 
and pruritus, which later on gives way to active ulceration, with 
discharge. 

In the present state of our knowledge of the etiology of malig- 
nant disease, it is only possible to state that the ear furnishes the 
same field for its development, though to a somewhat less degree, 
as other portions of the body. Its exposed position tends to aggra- 
vation of the symptoms on account of mechanical irritation. They 
progress more slowly than in other tissues, and glandular compli- 
cations also appear later, general infiltration is slower, and opera- 
tive treatment, when instituted early, may be considered more 
hopeful, especially in the ephithelial form. 

These somewhat favorable conditions arise from the fact that 
cartilaginous tissue absorbs any form of infection slowly. Even 
after the ulcerative stage has become well established, it is quite 
possible to successfully and permanently eradicate the disease by 
operation. The diagnosis may be obscure previous to the stage of 
ulceration, and must be based upon the characteristics of the malig- 
nant nodule. The ulceration is characteristic and usually unmis- 
takable. In suspected cases, and in all cases of ulceration of the 
auricle or external auditory canal characterized by exuberant 
granulations, eroded surfaces, elevated borders, and, later on, 
necrotic areas in the cartilage, sections should be removed for 
microscopic examination. 

Treatment. — But one general form of treatment for malignant 
growths of the auricle is worthy of consideration. In every instance 
and under all circumstances and conditions, barring advanced cases, 
the entire mass should be removed by means of the knife. The 
incision should be carried well into the surrounding healthy tissue, 
in order that no trace of the disease remains. The plan of proce- 
dure will depend upon the limits of the area of tissue involved. 
At times it becomes necessary to remove the entire auricle in order 
to reach the limits of the disease, an operation which is entirely 
permissible on account of the favorable results whi-ch may ensue. 
In amputating the pinna it is important, if possible, to preserve 
the epithelial lining of the meatus by suturing it to the edges of the 
skin at the external surface of the wound, thus insuring an open 
meatus. Unfortunately this is seldom attainable for the ulceration 
has usuallv extended too far into the canal, in which event some 



DISEASES OF THE EXTERNAL EAR. 157 

form of tube should be introduced and kept in situ until the wound 
heals. Even with the tube, atresia of the canal may result, requir- 
ing- some form of plastic operation. Skin grafting may be attempted, 
providing open surfaces remain, the grafts being so applied as to 
tend to maintain the lumen of the canal. Infiltration of the parotid 
gland is serious, and indicates progressive general infection. 




Fig. 94. — Epithelioma of the auricle. (Author's case.) 

Removal of the tumor under these circumstances is unwise and 
attended with extreme danger to life. Facial paralysis usually con- 
traindicates operative measures. 

Where only portions of the auricle are removed, a careful study 
should be given to the best means to be employed in molding and 
shaping the remaining portion of the ear so as to maintain as nearly 
as possible the normal position. Surgical principles should be fol- 
lowed in the removal of nearby lymphatic enlargements. 

Much has been written of the merits of the X-ray and radium 
applied for the cure of superficial carcinoma. While there seems 



158 



THE EXTERNAL EAR. 



to be well authenticated evidence that these measures tend to 
retard cell proliferations in some individuals, the author is still 
doubtful as to permanent benefit. 

These measures should never be relied upon to the exclusion 
of the knife, but are worthy of trial in inoperable cases, and to 
prevent recurrence after surgical extirpation. 




Fig. 95. — Same as Figure 94. Later stage of the disease. 

Fig. 95 illustrates a case which was attended by some unusual 
incidents :- 



and prevented sleep, the pain was located in the car 

~ consulted her family physician, who found the canal swollen, 

inflamed, and bathed in discharge. His diagnosis was acute purulent otitis 



media 



e pain 



mecna. 

About September 1st the discharge became offensive and the 
increased. There was no mastoid tenderness, but the probe came in con 
tact with exposed bone along the floor and posterior wall of the canal. 



DISEASES OF THE EXTERNAL EAR. 159 

At this time the mastoid was opened by the family physician, who 
found no pus or necrosis therein, but much pus and granulation in the 
external auditory canal. The posterior wound healed promptly, but there 
was no cessation of discbarge from the canal, while the pain became so 
severe that morphine was commenced. 

I first saw her in consultation on September 24th. There was much 
swelling and granulation tissue in the canal, offensive discharge, and the 
posterior inferior canal wall was necrotic. All typical symptoms had become 
obscured by the previous operation. There was no external swelling. 

A complete radical mastoid operation was performed at this time. 
There was no involvement of the mastoid antrum, but the attic and poste- 
rior canal wall were necrotic and covered with granulations. ' This was all 
carefully scraped away and the posterior wound sutured. 

There was no appearance of a neoplasm, and the scrapings when submitted 
to the laboratory gave no evidence of such a growth. 

Subsequent history, however, of continuous pain, profuse uncontrol- 
able malodorous discharge, gradual opening of tbe healed posterior wound, and 
general protruding of the entire pinna, with a peculiar neoplastic appearance 
of the granulation masses, was sufficient evidence for a diagnosis of ma- 
lignancy. Accordingly, a section was sent to the laboratory of the Man- 
hattan Eye, Ear, and Throat Hospital, in January, 1903. Laboratory report 
was as follows: — 

"Proliferation of granulations. Regular in appearance. 

"Microscopic examination: This specimen is a typical example of a 
flat-celled epithelioma, contiguous to the areas of a typical epithelium and 
others of round-cell granulation tissue. In one area of this granulation tis- 
sue there is a detached island of the epitheliomatous tissue. Some of the 
blood-vessels are plugged with abnormal epithelial cells. 

"Signed : Jonathan Wright." 

By this time there was much swelling of the entire auricle, but 
no glandular complications. 

About this time the patient was exhibited at a meeting of the New 
York Otological Society, and varying opinions were expressed as to the 
treatment, some members advising complete excision of the entire pinna, 
and others recommending treatment by either X-ray or radium. 

The patient was advised to have the pinna removed. She refused 
further operative interference of any form, and was referred to Dr. Robert 
Abbe for treatment with radium. Several applications of radium were made 
under his direction, apparently without any effect on the disease, her pain 
being aggravated for some hours after each sitting. The X-ray proved 
equally ineffective. 

The infiltration gradually extended over the mastoid and squamous 
regions and throughout the pinna, the latter being gradually eaten away. 
(Fig. 95.) 

During August, 1908, facial paralysis appeared, not, however, as a 
result of involvement of the parotid gland. 

She became much emaciated, with constant pain, which yielded only 
to large doses of morphine, and died from exhaustion in December, 1908. 

Sarcomata. — This variety of malignant neoplasms rarely 
develops primarily in the external ear, being- less frequent than 
epithelioma. Occasionally the auricle becomes the seat of second- 
ary deposits from adjacent sarcomatous tissue, notably the cervical 
regions (Fig - . 96). 

Development may be slow or rapid, depending upon the 
variety of cell proliferations, the small round-cell type tending to 
rapid growth. Sarcoma nodules are softer and more vascular than 
carcinoma, and ulceration takes place later. The spindle cell and 



160 THE EXTERNAL EAR. 

fibrosarcoma develop slowly, after remaining practically inert for 
indefinite periods. 

Disintegration is characterized by ulceration, with raw granu- 
lating surfaces of fungoid appearance, exuding unwholesome- 
appearing secretion, which may be sanious, watery or purulent, with 
a tendency to bleed upon the slightest touch, while the clinical 
appearance is usually sufficient to establish a diagnosis bevond 
reasonable doubt. It may wisely be reinforced by microscopical 
examination of a section obtained from the suspected growth. 




Fig. 96. — Postauricular osteosarcoma. (Patient of Dr. E. Terry Smith.) 

Prognosis. — The prognosis is invariably bad, except in the 
primary giant-cell type, when by early and complete removal a 
permanent cure is possible. 

Treatment. — Destruction by caustics and galvanocautery is 
contraindicated. The treatment for sarcoma is precisely that recom- 
mended above for epithelioma — viz., radical extirpation with the 
knife, if possible, before the stage of ulceration. Advanced cases 
which give evidence of extensive ulceration, or involvement of the 
temporal bone, or parotid gland, should be considered inoperable, 
and sufficient morphine should be administered to control the 
attendant pain and suffering, until death occurs. 



DISEASES OF THE EXTERNAL EAR. 



161 



NEW GROWTHS IN THE EXTERNAL AUDITORY MEATUS. 

The external auditory canal sometimes becomes the seat of 
various forms of new growths, which may be classified as benign 

ifectious granulomata. 

Benign Growths. 

Of the benign tumors, polypi, enchondromata, and bony 
neoplasms are the chief. Polypi almost invariably spring from 
some portion of the tympanic cavity and never from any portion 
of the external auditory canal, except its walls have become the 
seat of some form of chronic purulent inflammation. The treat- 
ment of aural polypi is described in Chapter VIII. 



Fig. 97. — Exostosis of the 




(Partly schematic.) 



Enchondromata. — Enchondromata in this location are ex- 
ceedingly rare, although they sometimes occur and usually result 
from some prolonged irritation or injury in the outer portion of the 
canal. They are always amenable to treatment by removal, and 
show but slight tendency to recurrence. 

Exostoses of the External Meatus.— Exostoses spring from the 
bony portion of the external auditory meatus, and furnish by far 
the larger portion of all benign growths developing in this location 
(Fig. 97). Various causes have been assigned, no one of which 
furnishes sufficient evidence to explain every case. It is, therefore, 
assumed that the disease may originate from several sources, among 
which may be mentioned :— 

(a) Rheumatic or gouty diathesis, which may predispose. Clinic- 
ally, there is no apparent evidence that gout ever leads to the 
formation of exostoses in the external auditory meatus. 

(b) Chronic purulent otitis media. In the author's experience 
they have usually been found in canals which have long been sub- 
ject to the discharge from a chronic purulent otitis, resulting from 
the prolonged irritation of said discharge, or as a result of the 
manipulation connected with its various forms of treatment. Sup- 
puration may have ceased, leaving evidences of its former ravages. 

it 



162 THE EXTERNAL EAR. 

They do, however, occasionally develop in the canals of those who 
have never suffered from otorrhea. 

(c) Heredity. In two or three instances meatal exostoses have 
been observed in several individuals in the same family. 

(d) Race. It has been noted that certain races are more liable 
to exostoses, the percentage being greater among Europeans. The 
Hawaiians also manifest a tendency to exostosis of the canal, which 
may be explained as arising from the irritation of prolonged and 
frequent immersion in salt water incident to their habits. The 
skulls of the aborigines show a preponderance of meatal exostoses. 

(e) Traumatism. The favorite location, aside from the postero- 
superior wall, is at the junction of the cartilaginous and bony por- 
tions. Occasionally, these outgrowths are pedunculated, although 
wide bases are often seen, and at times they assume a sessile 
form. The tumors are usually extremely dense and hard, although 
considerable cancellous material will be observed in some. 

So long as exostoses remain small in size, no subjective symp- 
toms are noted.' They are of slow growth, and years may pass with 
no symptoms pointing to their presence ; indeed, it is quite possible 
for them never to assume sufficient size to produce any symptoms 
whatever during the life of the individual. The first notable 
symptom appears when the size of the growth becomes sufficient 
to interfere with audition, the sensation being that of fullness in 
the ear and diminishing audition. Occlusion of the canal lumen by 
exostoses gives rise to pressure symptoms of an annoying type, 
often with decided neuralgic pain and disagreeable autophony,. 
while tinnitus becomes troublesome. The impingement of an 
exostosis upon the membrana tympani may eventuate in pressure 
necrosis of this membrane, and thus open up the tympanic cavity 
to infective inflammation. 

The diagnosis is never difficult to the experienced eye.. The 
osseous nature of the growth, its location and immobility, render 
the diagnosis easy and simple. There is no external evidence 
visible, and a good reflected light serves for purposes of inspection. 
In some instances the tumor will be found covered with cerumen ; 
in others the patients' attempts to remove the cerumen leaves a. 
more or less ulcerated surface, thus obscuring the diagnosis. 
Ordinarily there is no reddening, roughness, or ulceration of the 
surfaces, but rather a covering of smooth, shiny integument. 
Removal of the cerumen restores the outlines. 

A patient now under observation has a very large exostosis, 
which nearly fills the lumen of the tube. It does not, however, 
seriously interfere with hearing, and he complains of no symptoms 
except at such times as the small remaining segment becomes 
clogged with cerumen or epithelial debris. Thirty-six years ago 
the growth had been pronounced epithelioma of the canal. There 
is no history of purulency, the growth has been present for a period 
of about forty years and still does not interfere with audition or 
manifest any annoying symptoms. 

Prognosis. — These neoplasms are never dangerous to life, and 



DISEASES OF THE EXTERNAL EAR. 163 

impairment of hearing occurs only after the canal becomes com- 
pletely occluded. They develop slowly, their progress varying in 
different individuals and under different circumstances. When 
accompanied by otorrhea, growth is evidently more rapid. There 
is much doubt whether, under any circumstances, they ever assume 
a malignant type. They are always amenable to surgical removal, 
with no tendency to recur ; hence, prognosis may be considered 
good. 

Treatment. — Unless located sufficiently near the drum to 
cause pressure symptoms or ulceration, tumors of small size which 
produce no symptoms require no treatment. The size and location 
of the growth should be noted, and a drawing made upon the 
patient's history chart for purposes of reference. He should be 
informed of the condition and instructed to appear from time to. 
time for observation. Furthermore he should be warned that at 
some time operative interference might become necessary, to relieve 
pressure and maintain audition. As a preventive measure, the 
employment by patients of any mechanical means for the removal 
of cerumen, whereby the surfaces of the tumor might be irritated, 
should be forbidden. 

While it is unnecessary to interdict sea-bathing, the ear should 
be stuffed with cotton to prevent the entrance of salt water, which 
might otherwise irritate the growths, and, in addition, the general 
employment of fluids in the canal should be avoided, except when 
necessary to remove impacted cerumen, and then only by the 
attending physician. Surgical procedures only are worthy of con- 
siderations for the eradication of these growths, and the indica- 
tions for their removal are as follows : — 

(a) Impairment of hearing on account of occlusion. 

(b) Relief of pain and other pressure symptoms. 

(c) To terminate ulceration caused by impingement of the 
neoplasms upon the drum membrane, or upon each other. 

(d) To facilitate local treatment of an accompanying purulent 
otitis media. 

(e) Invariably as a step in the performance of a needed radical 
mastoid operation. 

The exact mode of procedure to be followed in the removal of 
exostoses depends upon their site, kind of base, and whether 
multiple or single. Neoplasms situated near the external orifice, or 
those with narrow bases located more deeply in the canal, are 
amenable to removal through the external orifice, and under local 
anesthesia by means of deep injections of cocaine. Following the 
ordinary measures of asepsis, the skin is incised and the periosteum 
elevated. A fine narrow chisel is now introduced and held firmly 
to the base of the growth, and a few taps of the mallet will 
suffice to separate the growth from its attachment, with but little 
danger of puncturing the drum or otherwise wounding the deeper 
structures. Any remaining roughness about the site may be 
smoothed by scraping with a curet or by the dental burr, the 
latter to be employed with great caution on account of the danger 



164 THE EXTERNAL EAR. 

of accidental injury to the surrounding tissues, and it is never to be 
used by the inexperienced. 

Deep-seated, broad-based and multiple exostoses are more 
skillfully, thoroughly, and safely ablated by detaching the auricle 
by a posterior incision, similar to that employed for the mastoid 
operation, under general anesthesia, although it is quite pos- 
sible to perform the operation painlessly, by injecting a solution of 
cocaine deeply at points under the skin and periosteum of the 
mastoid and posterior canal wall. After proper preparation of the 
surface to be incised, a Wilde incision close to the auricular attach- 
ment is carried directly down to the mastoid bone. The periosteum 
is then retracted forward only to the border of the bony canal, and 
then without break the elevator is directed inward along the canal 
wall, lifting the periosteum of the canal forward until the exostosis 
comes into full view. In skillful hands it is usually possible to 
reach this step without danger to the drum, or tearing through 
the integument covering the neoplasm. The growth should now 
be separated by means of a small, sharp chisel, driven home with 
a few taps of a mallet, and the rough surfaces smoothed by scraping 
with a curet. After washing away all debris and clots from the 
wound, the tissues should be replaced throughout and the posterior 
wound sutured. It is a wise procedure to pack the external canal 
quite firmly with sterile gauze for three or four days, in order to 
hold the replaced soft tissues firmly in place and maintain its 
patencv. There is no external deformity following this operation, 
and the linear scar from the incision is scarcely observable after a 
few months. 

One of the author's recent cases : — 

E. A., aged 21, purulent otitis media in childhood, and complained of 
tinnitus, increasing deafness, and, more recently, pain in the right ear. 

Diagnosis. — Large sessile exostoses upon posterior and superior canal 
walls, pressing upon the drum membrane. He was operated upon by poste- 
rior incision as above described. 

Examination after a lapse of three months; hearing normal, no tinnitus 
and no pain, and the external auditory canal is patent. 

When removing an exostosis during the progress of a radical 
mastoid operation, it is advisable to excavate the bone deeply 
throughout the bony canal, and thus avoid the narrowing and con- 
traction which is prone to follow these operations, and here the 
usual Map is constructed from the membranous canal. In suitable 
cases an ossiculectomy may be performed simultaneously with the 
external operation for ablation of an exostosis. There is no scien- 
tific basis for treating these growths by resorting to laminaria tents, 
electrolysis, X-ray, or antirheumatics. 

Angiomata. — True cavernous angioma of the external auditory 
canal does not occur except in conjunction with other larger sur- 
rounding areas. The affection is fully described under the heading 
"Angioma of the Auricle." 

Myxofibromata. — Myxofibromata, while found occupying the 



DISEASES OF THE EXTERNAL EAR. 165 

external auditory canal, usually spring from some portion of the 
tympanic cavity. 

Osteosarcomata. — The growth is rare in this location and 
seldom occurs primarily, but rather as an extension from the jaw 
or temporal bone. Any operation involves a coincident removal 
of the entire mass. 

Epitheliomata. — Epitheliomata develop primarily in the exter- 
nal meatus in a considerable proportion of all malignant neoplasms 
which spring from the auricle. They also appear as a result of 
extension from contiguous structures, even from the tonsil. The 
course and treatment have been described on page 156. 

NEW GROWTHS ON THE MEMBRANA TYMPANI. 

The membrana tympani may become the seat of a variety of 
new growths in the form of vascular tumors, or epithelial neo- 
plasms. It may also be the seat of infectious granulomata, tuber- 
culous ulceration, and syphilis. Occasionally inflammatory or 
hemorrhagic cysts appear, while calcification is of common occur- 
rence. Malignancy does not appear primarily, but may extend from 
other localities and involve the drum membrane. Inasmuch as 
these affections are described in detail in their appropriate chapters, 
they are merely mentioned here, and only for the systematic arrange- 
ment of topics. 

NEW GROWTHS IN THE EUSTACHIAN TUBE. 

Outgrowths in the form of connective-tissue proliferations, 
granulation tissue, polypoid excrescences, and fibrosarcoma spring 
from the membranous surfaces of the Eustachian tube, while denser 
neoplasms like hyperostosis, exostosis and calcification involve the 
cartilaginous and bony portions. The Eustachian tube may also 
become the seat of infectious granulomata, tuberculosis, and syphi- 
litic gummata. 

NEW GROWTHS IN THE MASTOID ANTRUM AND CELLS. 

Polypi and Granulomata. — Polypoid degeneration and granu- 
lation-tissue proliferation are common in this region, where they 
usually complicate purulent otitis media. These outgrowths spring 
from diseased surfaces of the antrum, the mastoid cells or epitym- 
panum. They may occur single or multiple. As the mass increases 
in size it invades the tympanic cavity, thence through the aperture 
in the drum, often reaching to the mouth of the external meatus. 
Those of large size are usually pedunculated, and have been divided 
into ordinary hard, round-celled and mucous polypi, fibromata, and 
myxomata. Of these the simple granulomata are by far the most 
common, and often during the course of a mastoid operation 
surprisinglv large quantities arc excavated. 

Infectious granulomata, a term here applied to syphilitic and 
tuberculous neoplasms, are occasionally found in the mastoid 



166 THE EXTERNAL EAR. 

process. They consist of a desquamative inflammatory process, 
associated with the active formation and breaking down of epithelial 
cells, from the superficial epithelial layer of the middle ear and its 
adnexa. The epithelial formations consist of large polyhedral cells 
with nuclei, resembling epidermal cells, and frequently containing 
cholesterin crystals between the individual layers. 

Treatment. — Removal by either the simple or radical mastoid 
operation. 

Cholesteatoma of the Temporal Bone. — The seat of choleste'a- 
tomata is usually at the upper and outer portion of the tympanic 
cavity, often involving the epitympanic space, and mastoid antrum. 
Their tendency is to grow upward and develop into organized 
masses, which press upon and ultimately destroy the mastoid cell 
walls. If a cholesteatoma has existed for a long period of time, 
large pneumatic spaces will be found occupied by the mass, their 
walls being composed of ivory-like, eburnated bone. These large 
spaces always connect with the tympanic cavity. The above con- 
dition does not usually take place before the thirtieth year 
(Virchow). The development of cholesteatomata is often attended 
with considerable danger, on account of its tendency to invade and 
destroy the bony structures, in which event infection may second- 
arily be carried to the meninges or large blood-vessels. Demonstra- 
tions by Kershner have proven that cholesteatomata possess the 
power to migrate into apparently healthy bone and to invade even 
the Haversian canals. 

The radical mastoid operation is the only feasible measure for 
the cure of this condition. Even after complete excavation, recur- 
rences are common, often necessitating repeated operations. 



SECTION III. 

The Middle Ear. 



CHAPTER XIV. 
DISEASES OF THE MIDDLE EAR. 



DISEASES AND INJURIES OF THE MEMBRANA TYMPANI. 

The membrana tympani occupies an intermediary position in 
which it completely divides the external from the middle ear, its 
outer (dermal) layer being continuous with the skin of the external 
meatus, and its inner (membranous) layer with that of the tym- 
panum. It is therefore liable to participate in the diseases both of 
the external meatus and the middle ear. 

Idiopathic inflammation of the drum membrane is extremely 
rare. A vast majority of its diseases originate in the adjacent struc- 
tures on either side. Bezold and Siebenmann 1 contend that, inas- 
much as so-called acute and chronic myringitis is so rarely unas- 
sociated with simultaneous inflammation of the external or middle 
ear, they should not be given an independent classification, while 
Politzer 2 advocates in strong terms his belief that primary myrin- 
gitis with distinct pathological changes does occur, and, further, 
that it is sometimes induced by pathogenic organisms. He lays 
much stress upon the slight interference with the hearing function 
in myringitis, even when it extends beyond the confines of the drum 
to the tympanic walls. It is the opinion of the author that primary 
idiopathic inflammation of the drum membrane is exceedingly rare, 
and that in no instance where the inflammation of the drumhead 
is secondary to disease of the adjacent structures should the term 
myringitis be employed. 

ACUTE MYRINGITIS (PRIMARY ACUTE INFLAMMATION OF 
THE MEMBRANA TYMPANI). 

Etiology. — The chief etiological factors are localized infection 
of the drumhead from traumatism, and local irritants in the form 
of caustics, impact of cold water from sea-bathing or douching, and 
foreign bodies. The disease may extend over the entire surface of 
the membrane and penetrate the entire structure; or it may be 
superficial. 

Symptoms. — The initial symptom is severe pain in the ear, 
often radiating in all directions, sometimes preceded by a sensation 



1 Text-book of Otology, p. 123. 

2 Diseases of the Ear, p. 280, 

(167) 






168 THE MIDDLE EAR. 

of fullness lasting for several hours. In severe cases the pain radiates 
■over the parietal region. Tinnitus is usually present, with slight 
disturbance of hearing which persists until the disease subsides. 
Some rise of temperature may be expected in young children. 
Examination of the drum membrane reveals localized inflammation, 
varying from a moderate congestion, which is confined to the dermal 
layer without exudate, to severe swelling with intralamellar exuda- 
tion. in the form of blebs rilled with serum. Petechial spots in the 
membrane are sometimes visible. ' After a 'few hours the blebs 
rupture externally, and healing gradually ensues after exfoliation of 
the dermal layer has taken place. For some time after the rupture 
of the blebs, considerable moisture will be found in the canal, while 
the desquamative period is characterized by the presence of 
detached flakes and shreds in the inner portion of the canal. Reso- 
lution is usually rapid, the congested appearance of the membrane 
gradually subsiding upon the formation of new epithelium. 

Diagnosis. — It is difficult to differentiate myringitis from acute 
catarrhal and the early stage of acute purulent otitis media. Otitis 
media of either type is usually preceded by an attack of acute rhino- 
pharyngitis, and there is marked loss of hearing from the com- 
mencement, while in myringitis there is but slight interference with 
the hearing function at any stage. In purulent otitis media the 
pain is apt to be persistent an-d to increase in severity until the 
drum membrane ruptures. There is also marked bulging of the 
entire drum after a short interval. Even though a discharge ap- 
pears in myringitis there is no perforation of the drum membrane. 
Myringitis is of shorter duration than acute catarrhal otitis media 
and usually terminates in recovery without permanent pathological 
changes in the tissue of the drum. Even when cuts, scratches and 
blebs have been present with copious exudation, recovery usually 
takes place without loss of hearing. 

Treatment. — The course of treatment depends upon both the 
causative factors and the severity of the case. In simple cases 
unattended' by blebs or traumatism the treatment is palliative. If 
the pain is severe codeine may be administered in doses of one- 
fourth grain every three hours until relieved, and the patient should 
remain indoors for a day or two and subsist upon a light diet. 
Local treatment of the drum is unnecessary . The hot-water bag 
applied to the ear relieves pain. 

As soon as the acute symptoms begin to subside, the patient 
may be permitted to go about his daily duties. When the inflam- 
matory process is sufficiently sudden and severe to produce blebs 
or blisters, they should be incised at once, the incision to penetrate 
only the dermal layer of the drum, inasmuch as perforation of the 
inner layer permits infection to enter the tympanic cavity. In order 
to obviate possible infection through the incision, the operation 
may be preceded by douching the external canal with a warm 
bkhlorid of mercury solution and carefully wiping with sterile 
cot ion, and likewise pledgets of sterile gauze may be placed in the 
external meatus until the surface of the drum becomes healed. 



THE MEMBRANA TYMPANI. 169 

Should the cause of the attack be traumatism wherein the rupture, 
laceration or cut extends entirely through the drum membrane, 
there arises the danger which would result from the entrance of 
pathogenic bacteria into the tympanic cavity ; indeed, in a limited 
proportion of cases of this nature, purulent otitis media ensues in 
spite of all preventive efforts. To combat infection the canal should 
be douched at once with a bichlorid of mercury solution and care- 
fully wiped clean and dry with sterile cotton. A pledget of sterile 
gauze lightly packed into the outer orifice of the canal will serve as 
a protection to the drum. The drum membrane and canal should 
be inspected daily and all moisture and debris removed at each 
sitting. Any resultant tinnitus or slight deafness will usually yield 
to moderate inflation, which procedure may be inaugurated after 
the acute symptoms have subsided. 



TRAUMATIC LESIONS OF THE MEMBRANA TYMPANI. 

General Remarks. — Diseases of the drum membrane, barring 
injuries, are almost invariably those associated with the different 
types of affections which originate primarily in the external audi- 
tory meatus, or still more commonly in the middle ear and its 
adnexa. The various pathological changes in the membrana 
tympani and their significance are fully described in the chapters 
covering the diseases of the external and the middle ear. 

Traumatism. — Traumatism of the membrana tympani results 
from: (1) Direct violence. (2) Indirect violence: (a) By sudden 
condensation of air, either in the external canal or tympanic cavity, 
and occasionally by sudden rarefaction of air in the external meatus. 
(b) By extension from a fracture of the temporal bone. 

Direct Violence.' — The location of the membrana tympani, 
deep in the somewhat tortuous external auditory canal, the outer 
aperture of which is afforded considerable protection from invasion 
by the lid-like tragus, is such that it is seldom the seat of direct 
traumatism. 

Direct injuries to the drum membrane may be self-inflicted or 
wholly accidental. 

Those first mentioned occur in the form of wounds from bullets, 
sword or stiletto thrusts, portions of shells ; the thrust of sharp- 
pointed objects like hatpins, sharp sticks, received accidentally or in 
combat, and from the impact of portions of explosives, flying sparks, 
chips and stones, and from clumsy attempts to extract foreign 
bodies from the external meatus. Twisting or pulling the auricle 
has been known to tear the drum membrane in its upper segment. 
Occasionally a rupture occurs from accidentally puncturing the 
drum from within while passing the Eustachian bougie. Self- 
inflicted injuries usually arise from digging, scratching or picking 
the ear with a pointed or sharpened instrument for the relief of 
meatal pruritus, or the removal of scales, cerumen or foreign bodies. 
The usual implements employed for this baneful procedure are ear- 
spoons, hairpins, toothpicks, penholders, matches, lead pencils and 



170 THE MIDDLE EAR. 

the earpieces of spectacles. There is considerable variation in the 
location and size of direct injuries to the drum, depending upon both 
the course of the canal and whether the implement is sharp, blunt, 
smooth or jagged. Most of the injuries, however, are located in 
the upper segment. In recent injuries it is possible to obtain a 
clear outline after all extravasation of blood has been removed, 
while later on the infiltration may be so extensive as to render the 
outlines of the wound unrecognizable. In rare instances sharp 
penetrating instruments or projectiles pass entirely through the 
drum membrane and invade the labyrinth, producing serious and 
even fatal results. 

During the preparation of this chapter the following unusual 
case came under the observation of the author: — 

Patient X, aged 38, blacksmith, with an unusually large and- straight 
external meatus and a small tragus, which nowise obstructed its orifice. 
Ten days previously, while swinging a piece of red-hot iron in an upward 
and downward direction preparatory to plunging the same into cold water, 
a spark flew directly into his left ear. He was immediately seized with 
violent, deep-seated earache, which continued for about eighteen hours. 
Some sweet oil was poured into his ear on several occasions, and no other 
treatment was given. After two days a mucopurulent discharge appeared, 
and he complained of moderate tinnitus and slight deafness. Upon exami- 
nation there was a slight, nearly healed excoriation at the orifice of the 
meatus; otherwise the entire external canal was free from evidence of in- 
jury. There was a large, grayish slough upon the drum membrane, cover- 
ing about one-fourth of its surface and located in the upper posterior 
section, while the remaining portion was intensely inflamed and infiltrated. 
There was a small quantity of mucopurulent exudate along the floor of the 
canal. Upon inflation a distinct whistle was heard. After thorough cleans- 
ing it was found impossible to locate the chip of iron. Careful hearing tests 
showed but little loss of hearing by aerial conduction. The treatment 
advised was a warm 1:5000 bichlorid of mercury douche four times a day, 
the canal to be wiped dry with sterile cotton after each douche, light pack- 
ing of the outer orifice of the canal during the interval. The discharge 
continued about one week longer, after which the perforation healed without 
perceptible loss of hearing. 

With rare exceptions all extensive perforating wounds of the 
drum membrane eventuate in middle-ear suppuration, the probable 
source of infection emanating from the penetrating object. In 
neglected cases the open perforation permits an invasion of pyogenic 
organisms from without. The treatment of this form of injury is 
not unlike that of acute purulent otitis media. 

Self-inflicted injuries are usually less severe and rarely per- 
forate the drum membrane, although a few cases are upon record 
(Bezold and Siebenmann) where patients have not only torn open 
the drum membrane but have dislocated or dragged away the 
ossicles. Single scratches or bruises of the drum usually heal 
promptly and without suppuration, providing ordinary aseptic pre- 
cautions are followed out in the treatment. 

Indirect Violence. — -Indirect violence in the form of sudden 
condensation or rarefaction of air in the external meatus may 
produce complete rupture of the drum. It would seem that the 
drum membrane either entirely resists the sudden change in air 



THE MEMBRANA TYMPANI. 171 

pressure or sustains a rupture through all its layers, since partial 
rupture or extensive ecchymosis is rarely observed. 

These ruptures are slit-like, occasionally oval, with sharply 
defined edges which in recent cases are covered with hemorrhagic 
exudate. They are seldom multiple. The most common location 
Is the anterior inferior quadrant. Among the causes the follow- 
ing are enumerated : Condensation of air in the external meatus 
;as a result of blows (boxing the ear) ; diving from heights, bathing 
in the surf, explosions (dynamite, gunshot, cannon, mortars), falls 
upon the ear, and concussions from caissons, bell diving and light- 
ning strokes. 

The air douche employed for inflating the middle ear produces 
Tupture of the drum membrane only when it is the seat of scar 
tissue or marked atrophy. The same holds true of rarefaction in 
the external meatus, depending upon suction by otoscopic instru- 
mentation, kissing upon the ear, or atmospheric pressure in high 




Fig. 93. — -Rupture of the drum membrane due to concussion from 
"boxing the ear." 

■altitudes. Unfortunately, the concussion wave may be of unusual 
severity and extend through the ossicular medium to the labyrinth, 
with disastrous effect upon the auditory nerve terminals. Subject- 
ively, the symptoms of rupture in the order of occurrence are : loud 
;sound in the ear, violent but momentary pain, tinnitus (severe 
■cases are often accompanied by nausea- and vomiting and vertigo 
when the labyrinth is involved), slight deafness, Weber test heard 
in the injured ear (in labyrinthine cases of marked deafness Weber 
test heard in normal ear), suppuration in the majority of cases. 

Indirect Violence from Cranial Fractures. — Rupture or 
tearing of the drum membrane, when resulting from injuries to the 
skull from falls or blows, may occur independently of bony fracture, 
or more commonly in conjunction with fractures of the temporal 
bone. 

Since such ruptures are continuous with the bone fractures, 
they are located in the upper portion of the membrane and accom- 
panying luxation or fractures of the ossicles are occasionally 
observed. The symptoms are hemorrhage from ruptured vessels 
of the membrane, from the fractured diploe and from the labyrinth 
or meninges when those structures are implicated. A flow of cere- 
brospinal fluid occurs in occasional cases, 



172 THE MIDDLE EAR. 

Treatment. — Hemorrhage may usually be controlled by tam- 
poning the external auditory meatus with sterile cotton or gauze. 
In a patient coming under observation soon after an injury and 
without serious hemorrhage, the chief requirements are to remove 
accumulated exudation from the canal without disturbing the edges 
of the perforation. At the same time the canal walls should be 
carefully rubbed with alcohol or bichlorid of mercury solution 
1 : 4000 for purposes of disinfection. Furthermore it is important to 
prevent if possible the access of infection to the middle ear through 
the rent in the drum membrane. A loose sterile wad of. gauze or 
cotton placed in the outer orifice constitutes the most available 
protection against outside infection. During this stage instillations 
and douches do positive harm and are contraindicated. If middle- 
ear suppuration ensues the further treatment should conform to 
that advised for acute purulent otitis media, Chapter XVIII. 

Finally, since the otologist is often required to give expert 
testimony in suits for damages to the ear, it is important to 
carefully record even the minutest facts relating to the causation 
and history of every case of injury, to note the appearance of the 
external canal walls, membrana tympani, and in case of perforations 
the condition of those portions of the cavum tympani which may 
be inspected or felt with a probe, and to ascertain all symptoms, 
both objective and subjective. 

Politzer 3 lays much stress upon the medico-legal aspect of otitic 
injuries. 



3 Diseases of the Ear, p. 247. 




Fig. 99. — Vertical section through left temporal bone in the plane of the 
axis of the petrous portion. (From Bardeleben's Applied Anatomy, with 
permission.) The mastoid cells (red) are shown radiating from the antrum 
mastoideum. The lower part of the tympanic cavity is removed so as to expose 
the external auditory canal. The ossicles and the drum are seen from behind. 

Pharyngeal orifice of the Eusta- 
chian tube. 
Superior constrictor of the pharynx. 
Stylohyoid muscle. 
Styloid process. 
Digastric muscle. 
Facial nerve. 
Sternomastoid muscle. 
Splenitis capitis muscle. 
Stylomastoid artery. 
Mastoid cells. 



A, 


Antrum. 


M, 


B, 


Incus. 




c, 


Superior ligament of the malleus. 


N, 


D, 


Chorda tympani. 


o, 


E, 


Tensor tympani muscle. 


P, 


F, 


Malleus umbo. 


Q, 


G, 


Eustachian tube. 


R, 


H 


Fifth nerve. 


s, 


I, 


Internal carotid artery. 


T, 


K, 


Cartilage of Eustachian tube. 


u, 


L, 


Levator palati muscle. 


V, 



CHAPTER XV. 

DISEASES OF THE MIDDLE EAR. 

(Continued.) 



SURGICAL ANATOMY OF THE MIDDLE EAR AND 
EUSTACHIAN TUBE. 

Anatomy. — The middle ear consists of the Eustachian tube, the 
tympanic cavity and its contents, together with the aditus ad 
antrum, antrum mastoideum and mastoid process (Fig. 99). 

The tympanic cavity is about 15 mm. in height, 3 mm. in 
width, and from its anterior to its posterior wall measures about 
10 mm. It is a four-sided cavity, having three bony and one mem- 
branous wall, in addition to a roof and a floor. Its upper portion is 
anatomically differentiated from the tympanic cavity proper, being 
designated the aditus ad antrum. It is also termed the epitympanic 
space. This corresponds roughly to that part of the tympanic 
cavity situated above a line drawn horizontally at the level of the 
processus brevis. The head of the malleus and the body and short 
process of the incus are contained within this space (Fig. 100, F, G). 
This part of the tympanic cavity is often termed the "attic." 

Laterally (externally) the tympanic cavity is separated from 
the external auditory canal by the membrana tympani (Fig. 100, 
B). Above the floor of the aditus this wall is bony, made up of the 
outer wall of the aditus (Fig. 36). The anterior wall is really a 
convergence of the inner and outer walls, and the orifice of the 
Eustachian tube (Fig. 99, G). 

Above, the tympanic cavity merges into the aditus ad antrum, 
while posteriorly a hard, bony wall forms its lower boundary. 
Above this bony wall and within the region of the aditus an open- 
ing, the aditus proper, is shown leading to the .mastoid antrum. 
The roof of the aditus is the tegmen tympani. The floor of the 
tympanic cavity is a rather thin lamella of bone. It separates the 
dome of the jugular bulb 'from the tympanic cavity (Fig. 100, C). 
This lamella of bone occasionally presents defects (dehiscences), 
placing the blood-vessels in direct 'contact with the tympanic 
mucous membrane. The posterior wall of the tympanic cavity 
rises from the tympanic floor in a slight curve, and presents at its 
upper limits a number of pneumatic cells. This wall is limited 
below by a square ledge of bone, merging toward the median line 
into a pyramidal eminence from whose lateral end a small bony 
canal runs toward the facial canal. The canal of the facial nerve 
runs its course deeply down on the posterior tympanic wall. 

The mesial or labyrinthine wall of the tympanic cavity presents 
a rounded protuberance — the promontory (Fig. 100, D). This is a 
flat, rather hard bulging plate of bone formed by the basal turn of 
the cochlea. It presents a smooth surface toward the tympanic 

(173) 



174 



THE MIDDLE EAR. 



cavity, merging anteriorly into the wall of the Eustachian orifice. 
At its lower part, the labyrinthine wall is lost in the tympanic floor. 
Above, posteriorly, the wall presents the fenestra ovalis, while 
below, posteriorly, the fenestra rotunda is situated. 

The aditus ad antrum is a triangular prism-shaped space, 
leading from the tympanic cavity to the antrum mastoideum. 
This space is bounded anteriorly by the tensor tympani muscle 
together with a spur of bone — the crista transversa — situated just 
above the tensor tendon and by a series of mucous folds (plicae 
transversa) exceedingly variable in form and extent. These serve 




Fig. 100. — Partly schematic drawing from specimen (enlarged) after 
Siebenmann, showing: A, External auditory canal. B, Posterior surface 
of drum. C, Tympanic cavity. D, Promontory. E, Process brevis malleus. 
F, Malleus head. G, Incus. H, Tensor tympani. L, Suspensory ligament 
of malleus. M, Part of superior semicircular canal. N, Footplate of 
stapes seen from labyrinthine side. (From Kopetzky's "Surgery of the 
Ear," Rebman Co., Publishers.) 



to connect the tensor and the crista transversa by forming a curtain 
which occupies a position perpendicular to the longitudinal axis of 
the aditus (Siebenmann). Posteriorly the aditus ad antrum is 
gradually merged in the antrum mastoideum. 

Contained in the tympanic cavity and aditus ad antrum is a 
chain of small bones, the ossicles. These are three in number, the 
malleus, the incus and the stapes. 

With this general sketch of the anatomy of the tympanic cavity 
as a background, we take up some of its more important structures, 
which concern us more intimately in the study of the diseases of 
the middle ear. 

The Membrana Tympani (Fig. 101). — This is a translucent, 
pearly, delicate, smooth and glistening membrane, the borders of 




Fig. 101. — The normal membrana tympani. Both the artist and the 
author have combined in endeavoring to produce the normal color, contour 
and landmarks of the drum membrane in its entirety as seen through the 
speculum by reflected light. 



MIDDLE EAR AND EUSTACHIAN TUBE. 175 

which are attached to the slightly curved edge of the internal end 
of the bony auditory canal, called the annulus tympanicus. The 
membrana tympani is divided anatomically into the pars membrana 
tensa and the pars membrana flaccida (Fig. 102). The pars mem- 
brana tensa forms the chief portion of this membrane, while the 
pars membrana flaccida, or Shrapnell's membrane, is a small, cres- 
cent-shaped area lying above or superior to the processus brevis and 
the incisura Rivini. Shrapnell's membrane is not as obliquely placed 
as the neighboring portion of the pars tensa, and in the living sub- 
ject, especially, it is more or less distinctly differentiated from the 
latter by two flat folds known as the anterior and posterior folds of 
the membrana tympani (Fig. 102). 

In form the membrana tympani is irregularly oval, or elliptical, 
and the mar go tympanicus is often distinctly rounded off. At the 
incisura Rivini, or Rivinian fissure, which is made up of the break 
in the upper portion of the bony ring, the membrana flaccida, or 




POSTERIOR FOLD 



SHRAPNELL'S MEMBRANE^ 
ANTERIOR FOLC 

SHORT PROCESS 

MANUBRIUM ^ \. ^ |, UM BQ 

LiaKTMfLEX 

Fig. 102. — The landmarks of the membrana tympani. 

Shrapnell's membrane is rather loosely attached, which accounts 
for the greater mobility of this part of the drum. The form and 
size of the Rivinian fissure varies, averaging in height 2 mm. and in 
width from 2.5 to 3 mm. The exact form of the membrane is deter- 
mined by that of the surrounding ring. 

The membrana tympani is made up of three layers, the outer 
of which is continuous with the lining of the external meatus, and is 
composed of derma. The inner layer is a part of the mucous lining 
of the tympanic cavity, while between these two layers a third, 
or fibrous layer, is found. 

The size of the membrana tympani is not materially affected 
by age, for the reason that both the ring and the membrane are 
almost fully developed in very early life. 

The inclination of the membrana tympani depends upon its 
relation to the walls of the external meatus, observations and 
measurements varying with the angle from which the observation 
is taken. It is stretched obliquely downward and inward at the 
inner end of the bony meatus, so that its plane forms an obtuse 
angle with the upper wall and an acute angle with the lower wall 
cif the tube (Fig. 103). Anteriorly the angle is very acute, and 
posteriorly it is obtuse, because the plane of the drum is slanted in 
two directions. 

The membrana tympani presents a more or less concave 
surface, the dome of the concavity encroaching upon the tympanic 



176 



THE MIDDLE EAR. 



cavity. The deepest portion of the dome, the umbo (Fig. 102), 
marks the insertion of the distal end of the malleus handle between 
the layers of the membrane. 

The Light Reflex. — Illumination of the tympanic membrane 
brings to view a cone of light in the form of a triangle, the apex of 
which is near the umbo, the general direction being downward and 
forward toward the periphery, the base-line being rather poorly 
defined, parallel with and a short distance from the drum periphery 
(Fig. 102). Between Shrapnell's membrane and the neck of the 
malleus a marked depression is found, corresponding to Prussak's 
space. Here the mucous lining folds upon itself so that it passes 
over the chorda tympani nerve on the inner side of the membrana 
tympani. 




Fig. 103. — Lateral view, showing the normal relations of the external 
auditory canal, drum membrane, ossicles and tympanic cavity. Special 
attention is called to the angles formed by the drum membrane with the 
walls of the osseous meatus. 



Deviations in the anatomical relations in infancy and early 
childhood are referable to the incomplete development of the 
temporal bone at that age. 

The diseases of the Eustachian tube form a part of the diseases 
of the tympanic cavity, and, in the treatment of the diseases of the 
latter, attention to this important structure becomes of prime 
importance; therefore, a brief consideration of the anatomical 
peculiarities of the tube deserves attention here. 

Eustachian Tube. — Physiologically considered the Eustachian 
tube serves both as a ventilating apparatus for the middle ear 
and as the channel of communication between the rhinopharyngeal 
space and the tympanic cavity, for the purpose of .equalizing the 
ratio of pressure between the external air and that contained in the 
middle-ear spares. 

In direction the Eustachian tube passes from the upper anterior 
portion of the tympanic cavity inward and downward toward 
the pharyngeal vault. Its length in the adult is about 36 mm. For 
about one-third of the distance from the tympanic cavity the walls 



MIDDLE EAR AND EUSTACHIAN TUBE. 177 

of the tube are bony ; the remaining two-thirds are cartilaginous. 
The point of junction between the bony and cartilaginous portions is 
very narrow and is designated the isthmus (Fig. 99, g, k, m). The 
dimensions of the lumen of the Eustachian tube are subject to 
individual variations. Its walls are probably altogether closed at 
its middle portion while at rest, but they open during the act of 
swallowing. The lining membrane of the tube is made up of 
ciliated epithelial and goblet cells. The deeper layers of its struc- 
ture are made up of cartilage and bone in the outer one-third, and 
cartilage in the inner two-thirds. The layer of ciliated epithelium 
in the cartilaginous portion of the tube lies directly upon a layer 
of adenoid tissue of variable thickness. This adenoid stratum 
has been called the tubular tonsil (Gerlach and Teutlevan). 
In the young child the adenoid tissue of the tube is much 
more developed than in the adult, and assumes the form of 
prominent lymph follicles, hence occlusion of the tube occurs much 
more frequently in childhood than in later life because of swelling 
in the tissue. The mucous glands are acinous in structure and 
form a thick layer, frequently interrupted by a stratum of fibrous 
tissue. Isolated glandular ducts occur throughout the adenoid 
tissue. Both the mucous glands and the adenoid tissue decrease 
toward the isthmus of the tube. 

The cartilage of the Eustachian tube does not form a complete 
and rigid tube, but, like the trachea and the cartilaginous auditory 
canal, consists of a furrow, the open part of which becomes closed 
by membranous tissue, to form the tube. Ossification of the carti- 
laginous tube is apt to occur as a senile change. The lower end of 
the tubal cartilage projects to a variable degree into the rhino- 
pharyngeal space, and its posterior lip forms the back boundary of 
the triangular, funnel-shaped excavation, designated the ostium 
pharyngeum. The mucous lining of the posterior lip of this ostium 
contains an abundance of adenoid and glandular tissue. It has a 
diffuse and more or less vivid coloring, contrasting sharply with 
the more or less pale and yellowish tint of the .general tubal open- 
ing. Occasionally a salpingopharyngeal fold may be seen extend- 
ing perpendicularly into the mucous lining of the lateral pharyngeal 
wall springing from the ostium tuba. 

The bony walls of the tube gradually widen toward the tym- 
panic cavity without sharp differentiation. In the bony tube the 
mucosa is firmly united to a layer of thin periosteum and this is 
closely adherent to the bone. Mucous glands are very rare, only 
one or two being found in the adult Eustachian tube. Ciliated 
cylindrical epithelium is found throughout the mucous lining of 
the tube. The bony tube presents cells containing air and lined with 
mucous membrane, the cellular tubene, fully described by Bezold. 
These are of importance in radical mastoid surgery and will be 
reverted to later. Tn the adult they arise from the bottom, from the 
median wall and from the outer median angle of the tube. These 
are not present in the newborn, although by the end of the first half 
year of life they become plainly visible. 



178 THE MIDDLE EAR. 

In the newborn the membranous part of the cartilaginous tube 
predominates over the cartilaginous section. There is no percepti- 
ble isthmus at its junction with the bony tube, the os tympani 
being as yet imperfectly developed, but at the age of nine months 
the topography of the tube practically resembles that of the adult. 
The faucial orifice of the tube in the fetus lies below the horizontal 
plane of the hard palate, reaching the level of the palate at about 
the time of birth. At four years of age it is 3 to 4 mm. above this, 
according to Kunkel, and in the adult it is about 10 mm. above the 
level of the hard palate. In the young child the posterior lip of the 
tube does not present a distinct projection into the pharyngeal 
vault. 

Within the tympanic cavity and the aditus ad antrum and 
lying mostly in the latter is the ossicular chain, which is composed 
of the malleus, incus and stapes. 

The Malleus and its Ligaments. — The malleus, the largest of 
the three bones, is irregular in shape, being made up of the oval 
head, which gradually tapers into a narrow portion known as the 
neck. The neck converges into an expansion of bone, which forms 
two processes : (a) The processus brevis, a small tubercle below 
and posterior to which is attached the tendon of the tensor tympani 
muscle, is plainly visible on inspection from the external auditory 
canal, and constitutes one of the landmarks of the middle ear. (b) 
The processus gracilis, a long slender and somewhat fibrous proc- 
ess, which passes forward into the Glaserian fissure, and is only 
well marked at birth. The remaining portion of the bone gradually 
tapers into the long process (handle or manubrium), the distal end 
of which is imbedded between the layers of the membrana tympani, 
to which it is firmy attached. 

Four ligaments, the anterior, superior, external and internal, 
serve to hold the malleus in position. The anterior is attached to a 
groove found in the anterior portion of the neck and head, its other 
attachment being the wall of the Glaserian fissure and anterior wall 
of the tympanum, surrounding the processus gracilis. The func- 
tion of this ligament seems to be to limit "somewhat the motion of 
the malleus. 

The superior or suspensory ligament is attached to the tym- 
panic roof in its outer portion, also to the head of the malleus. Its 
function seems to be to hold the malleus firmly, limiting its motion 
downward and outward. 

The external ligament is fan-shaped, its broader attachment 
arising from the margin of the Rivinian notch, its apex from the 
neck of the malleus. By these attachments outward rotation of the 
manubrium is limited. 

The internal ligament is in reality the sheath of the tensor 
tympani muscle and therefore passes from the processus cochleari- 
formis to the inner surface of the malleus handle around the at- 
tachment of the tensor tympani tendon, its function being to limit 
the outward motion of the handle of the malleus. 

The Incus and its Ligaments. — The incus or anvil occupies the 



MIDDLE EAR AND EUSTACHIAN TUBE. 179 

central position in the series, its upper portion assuming the form 
of an anvil, and is made up of a body, a short and a long process. 
The short process presents rather more the form of a tubercle, 
being somewhat conical in shape, and its tip projects beyond the 
level of the floor of the aditus ad antrum (Fig. 99, B). The long 
process passes downward and backward, parallel with but at a 
plane deeper than that of the malleus handle, terminating in its 
attachment to the head of the stapes, the joint of attachment being 
known as the incudostapedial joint. At its lower portion it curves 
inward in order to unite with the stapes. The long process is also 
known as the lenticular process. The incus ligament is a fibrous 
band passing from the posterior extremity of the short process to 
that portion of the tympanic wall near* the mastoid antrum. 

The Stapes and its Ligaments. — The remaining ossicle, the 
stapes, is in direct communication with the auditory mechanism by 
the attachment of its foot-plate with the cavity of the oval window. 
The general form of the stapes is quite similar to that of a stirrup, 
and almost the entire bone is submerged in the pelvis ovalis, the 
head, neck and a small portion of each crus sometimes being visible. 
The stapes assumes an oblique position in the oval window, its 
position being nearer to the posterior and inferior walls of the fossa. 
Adhesions occasionally form between the posterior wall and the 
nearby stapedial crus. Various forms of adhesions, in fact, are 
found in this vicinity. „These are pathological. 

Surrounding the foot-plate of the stapes and confining it in 
position in the oval window is a ligament known as the stapedio- 
vestibular ligament. 

The remaining ossicular ligaments are of the capsular variety, 
covering the articular surfaces of these bones. 

The Intratympanic Muscles. — Two muscles are found in the 
tympanic cavity, the stapedius and the tensor tympani. The first 
originates in the interior of the pyramid, through the apex of 
which its tendon passes to be inserted into the neck of the stapes. 
This muscle receives its nerve supply from a branch of the facial, 
and it acts upon the head of the stapes by causing the bone to make 
pressure upon the contents of the vestibule. 

The tensor tympani muscle, larger than the stapedius, lies in 
a bony canal, running parallel to the Eustachian tube. It arises 
from the cartilage of the Eustachian tube, and from the surface of 
the great wing of the sphenoid, some fibres also arising from the 
walls of its own canal. Its tendon passes round the processus 
cochleariformis on the posterior tympanic wall, then turns outward 
into the tympanum, which it crosses to become attached to the 
inner surface of the malleus handle just a little below the level of 
the processus brevis. 

It receives its nerve supply from the motor root of the fifth 
nerve. This muscle has the power to make traction inward upon 
the malleus, thus controlling the tension of the membrana tympani. 

Blood-supply of the Middle Ear. — Tympanic branches from the 
internal maxillarv and internal carotid arteries, also from the stvlo- 



180 THE MIDDLE EAR. 

mastoid branch of the posterior auricular artery, the petrosal 
branch of the middle meningeal, together with a small branch of 
the ascending pharyngeal, furnish the blood-supply of the middle 
ear. 

The distribution of the veins of the middle ear is such that the 
venous blood escapes into the superior petrosal sinus, the lateral 
sinus, the internal jugular vein, the temporomaxillary vein and the 
pharyngeal veins, while a few small veins pass upward through the 
tegmen to communicate with those of the dura mater. 

The lymphatics of the middle ear form a part of the parotid 
and posterior auricular lymphatics. 

The chorda tympani is the nerve seen as a whitish streak, just 
below the posterior fold of the drum membrane, in Prussack's 
space. This nerve emerges from the aquseductus Fallopii above the 
eminencia pyramidalis and it crosses the tympanic cavity from 
behind forward between the long process of the incus and the 
handle of the malleus. Tt leaves the tympanic cavity through the 
Glaserian fissure to join the lingual branch of the trigeminus, 
reaching the Glaserian fissure bv the posterior fold of the membrana 
flaccida as designated above. The importance of this exact localiza- 
tion of this nerve becomes evident during some of the intratym- 
panic operations to be hereafter described. Its severance impairs 
the sense of taste of the injured side. 



CHAPTER XVI. 

DISEASES OF THE MIDDLE EAR. 

(Continued.) 

The most satisfactor}' classification of middle-ear diseases is 
obtained by adopting a pathological basis. 

Primarily, we divide the diseases of the middle ear into those 
which are bacterial and into those which are non-bacterial in 
origin. The non-bacterial diseases of the middle ear are known as 
"catarrhal," and those of bacterial origin we designate as inflam- 
mations. The latter are the lesions which result from the invasion 
of micro-organisms ; the former — the catarrhal — are due to the 
mechanical effects produced by closure of the Eustachian tubes. 
Both the catarrhal and the inflammatory groups of middle-ear 
diseases are divisible into acute, subacute and chronic types of 
middle-ear disease. Incidentally it is to be noted that the chronic 
catarrhal type of otitis media is distinctly different from another 
-chronic middle-ear disease, viz., otosclerosis. 

ACUTE MIDDLE-EAR CATARRH. 

Etiology and Pathology. — The pathological changes in this 
condition are largely confined to the pharyngeal portions of the 
Eustachian tube. There are few pathological changes in the struc- 
ture of the middle-ear spaces. The mucous membrane of the tube 
becomes reddened and swollen, the tube lumen narrowed or 
closed. The result of this closure of the lumen of the Eustachian 
tube is a retraction of the membrana tympani. This is a common 
clinical observation. The mucous membrane of the middle ear 
seems to have the property of absorbing the air contained in the 
middle-ear spaces (Boeninghaus). With the lumen of the tube 
closed by catarrhal swelling, this faculty of air absorption in the 
middle ear causes a negative pressure in the middle-ear spaces, and 
the air pressure in the external auditory canal forces the drum 
inward toward the promontory in an effort to establish compensa- 
tion. 

Regarding the air absorption within the tympanic cavity, little 
is known. Bezold regards it of similar nature to the air changes 
which take place in the lungs. Korner, on the other hand, regards 
the faculty as similar to the absorption of air which takes place in 
cases of pneumothorax, where the air is absorbed by the pleura. 
The air is taken up according to this authority by the lymph spaces 
in the mucous membrane. When the air absorption continues, the 
drum membrane is drawn inward (Fig. .36), and this process con- 
tinues until the elasticitv of the drum has reached its limit. The 
tendency to vacuum formation continuing, a hvperemia of the 

(181) 



182 



THE MIDDLE EAR. 



mucous membrane (Fig. 106) results, from which a transudate 
finally flows into the tympanic cavity (Fig. 104). 

The quantity of transudate which is exuded is commensurate 
with the amount of negative pressure within the tympanic cavity, 
and its formation ceases when this negative pressure has been 
balanced. 

The transudate is sterile, it having been examined by Scheibe 
(1892), Brieger (1896), Launois (1896), Kiimmel (1906), and found 
to contain no micro-organisms. Therefore, we class these cases 
with the non-bacterial involvements of the middle ear. The sudden 
closure of the Eustachian tube which is characteristic of catarrh of 
the Eustachian tube and tympanic cavity is immediately followed 
by diminished hearing, tinnitus and a sensation of fullness or stuffi- 
ness in the ears. 




Fig. 104.— Showing early- 
stage of serous transudate 
into the tympanic cavity as 
a result of an attack of 
acute catarrhal otitis media. 
(Partly schematic.) 




Fig. 105. — Con- 
gested blood-ves- 
ssls along the line 
of ths malleus han- 
dle. The drum 
membrane is re- 
tracted. 




Fig, 106. — Hyperemia of 
the blood-vessels of the drum 
membrane during the early 
stage of acute catarrhal 
otitis media. Note the re- 
traction which is character- 
istic of this disease 



Symptoms. — Pain is sometimes present but is never severe. 
Patients are prone to point to the region of the tonsil as the seat 
of pain, probably on account of the involvement of the Eustachian 
tube. 

The affection is more pronounced in children who have chronic 
rhinitis or are affected with adenoid vegetations and hypertrophied 
tonsils. 

In childhood the disease is often overlooked and usually 
neglected. It is only after the lapse of time, as the loss of hearing 
becomes gradually apparent to the parents or teachers, that the 
condition is brought under observation, and by this time it may 
have progressed into one of the chronic catarrhal forms. 

Upon examination, the hearing may be found much impaired. 
When much impaired the whispered voice is apprehended at but a 
short distance, or only at the concha. While the deafness is a char- 
acteristic symptom, the power for sound perception varies widely 
in different cases. At times the patient hears almost normally, and 
at other times he is exceedingly deaf. 

Adults complain of a feeling of "fullness" in the affected ear 



DISEASES OF THE MIDDLE EAR. 



183 



and pressure within the head, usually combined with tinnitus 
aurium. The tinnitus is characterized as deeply pitched, is not of 
strong quality, and often is only observed by the patient during 
the evening hours. More rarely it is loud and clicking in character. 

Autophonia, by which is implied a peculiar loud resonance to 
one's own voice, is sometimes a most annoying symptom. During 
the exudative stage the movement of the fluid within the tympanic 
cavity evokes variations in the hearing function, the hearing being 
worse when the patient is in the recumbent position. This, in brief, 
constitutes the clinical picture. 

Course. — As the causative factor becomes eliminated, that is, 
when the coryza, the rhinitis, epipharyngitis, etc., abate, the 
catarrhal condition in the middle ear and tube gradually sub- 
sides, except among children with adenoids or where the nasal 
condition of "cold" is quasi-permanent, in which event the tubal 






Fig. 107. — Showing 
upper level of tympanic 
transudate. Drum mem- 
brane retracted. 



Fig. 108. —Air bub- 
bles in the tympanic 
transudate, following 
inflation. (Partly sche- 
matic.) 



Fig. 109. — Change in 
the level of the fluid in- 
duced by tipping the pa- 
tient's head backward. 
(Partly schematic.) 



and middle-ear catarrh often persists for months and even years, 
until finally physiological involution of the adenoid tissue takes 
place at puberty, and then, if the changes in the middle ear 
have not become permanent, the catarrhal otitis subsides. 
Generally, however, irreparable damage has been done the hearing 
apparatus by permanent changes in the mucous membrane of the 
middle ear, and so fortunate a result as spontaneous recovery does 
not occur. Rupture of the drum membrane does not occur in 
uncomplicated otitis media of. the catarrhal form, inasmuch as the 
exudate is only compensatory and invariably non-bacterial. 

The appearance of the drum membrane varies with the stage 
of the disease. Soon after the onset it presents a reddish tint. It 
is retracted ; the concavity distorts the light reflex, and a patho- 
logical fold running from a point behind and below the processus 
brevis toward the posterior drum margin becomes evident. Shrap- 
nell's membrane is usually drawn inward, and presents a second 
light reflex — a pathological finding — at its point of greatest con- 
cavity. The malleus handle inclines toward the promontory, ap- 
pearing foreshortened. The processus brevis is usually sharply 
outlined. The blood-vessels of the drum are injected, especially 



184 



THE MIDDLE EAR. 



about the malleus handle [Fig. 105). The reddish tinge of the 
drum is due to the hyperemic condition of the mucous membrane 
in the tympanic cavity, including' the mucous membrane layer of 
the drum itself (Fig. 106). 

When the transudate has formed, a transverse line of demarka- 
tion becomes visible on the drum surface, denoting the upper level 
of the fluid in the tympanic cavity (Fig. 107). There is no bulging 
of the drum membrane in the catarrhs of the middle-ear spaces, 
because the fluid collects only to the extent of compensating the 
negative air pressure. 

Diagnosis. — The diagnosis is based upon the otoscopic findings 
described above and this is substantiated by catheterization of the_ 




110. — Lateral view of the tympanum, showing air bubbles 
in the transudate. (Partly schematic.) 



affected ear and interpreting the auscultation sounds thus obtained 
(Fig. 108). The level of the transudate will be found to have 
changed after inflation, or, upon changing the position of the 
patient's head (Fig. 109), and, in addition, air bubbles are often 
noted (Fig. 110). 

Boenninghaus notes that in these cases postrhinoscopic ex- 
amination will often show the pharyngeal orifice of the Eustachian 
tube narrowed, having a somewhat yellowish tinge against the 
surrounding red of the pharyngeal vault. Often the tubal orifice 
is covered with secretions, and, where inflamed adenoid tissue is 
present (in children especially), there may be purulent exudate in 
the pharynx. 

In conclusion, the acute and subacute stages of acute catarrhal 
otitis media arc variations in the degree of involvement rather than 
of kind, and the extent of the involvement indicates either an 
isolated tubal catarrh, or, what is a much more common observa- 
tion, a tubal catarrh combined with varying degrees of catarrh of 
the middle ear. 



DISEASES OF THE MIDDLE EAR. 185 

Prognosis. — Prognosis is favorable whenever each attack is 
promptly relieved by appropriate treatment, but procrastination in 
treatment, or indifference as to the serious effects which are pro- 
duced by repeated attacks often result in the chronic form of the 
disease, and permanent damage may be reached during childhood. 

Treatment. — Having ascertained the nature of the immediate 
cause of an attack of acute catarrhal otitis media, the plan of treat- 
ment adopted should aim both to ameliorate or cure the primary 
affection and to restore the patency of the Eustachian tube. 

The treatment of inflammations of the nasopharyngeal mucosa 
is fully described in the chapters covering these topics wherein 
emphasis is given to : (a)" internal medication — cathartics, elimina- 
tives, vasomotor constrictors, etc. (b) Local treatment of the 
nasopharynx : cleansing sprays, soothing emollient applications, 
anesthetic and vasomotor stimulants, (c ) Surgical : the correction 
of abnormalities and deformities and the removal of adventitious 
tissues whether hypertrophied turbinates, mucous polypi, adenoids, 
hypertrophied tonsils or new growths. 

Ventilation of the Eustachian tube and tympanic cavity is of 
still greater immediate importance, for herein lies the only means 
of affording relief from the distressing symptoms and of shortening 
the course of the disease. Of the approved methods of tubal infla- 
tion the catheter is the most effective for this condition, inasmuch 
as an oft-repeated and prolonged application of the air douche is 
necessary. (See Chapter VIII.) 

As a preliminary to catheterization the nose and nasopharynx 
should be relieved of all accumulations of secretion and so far as 
possible made clean in order to minimize the danger of forcing any 
pathogenic- material into the deep portions of the tube or tympanic 
cavity. An application of a solution of cocaine 2 per cent, in 
adrenalin 1 : 5000 along the floor of the nares and about the orifice 
of the Eustachian tube serves the double purpose of reducing the 
swelling of the soft tissues and facilitating the introduction of the 
catheter. 

In children the removal of adenoids and hypertrophied tonsils 
often terminates the attacks of acute catarrhal otitis media without 
further treatment. The adenoid operation should never be per- 
formed during an acute attack. After .the removal of the adenoids 
the air douche should be continued for some time, until all signs of 
the disease have disappeared. One of the chief benefits of the 
various operations for the relief of intranasal obstruction lies in the 
fact that a prominent contributing cause of acute and chronic 
catarrh of the middle ear is at the same time eliminated. 



CHAPTER XVII. 

DISEASES OF THE MIDDLE EAR. 
(Continued.) 

CHRONIC MIDDLE-EAR CATARRH. 

Etiology. — The tissue changes involving the tympanic cavity 
and Eustachian tuhe in chronic catarrhal otitis media are of such a 
nature that they result in the production of new connective-tissue 
elements. These changes may result either from a long-continued 
inflammatory process or from a succession of acute attacks. These 
are usually traced to childhood and young adult life, during which 
attacks of inflammation of the nasopharyngeal mucosa attended 
with tubotympanitis, catarrhal or purulent, have been allowed to 
exist without proper treatment. 

It is often possible to determine a predisposing tendency in the 
form of intranasal diseases and deformities, or affections of the 
pharynx and fauces which serve as the primary factor in the 
development of this condition. Chronic affections, of the nose and 
nasopharynx extending to the middle ear through the Eustachian 
tube; adenoid vegetations in the vault of the pharynx; hyperplasia 
and bony enlargement of the turbinal bones; deflections of the 
nasal septum ; chronic pharyngitis, all of which render the nose and 
nasopharynx liable to frequent attacks of acute inflammation with 
or without marked infection, tend to produce tubal inflammation. 
Prolonged tubal obstruction materially affects the tissues of the 
tympanic cavity, and, by producing improper aeration of the cavity, 
materially aids in the development of tissue changes there. 

In young children diseased lymphoid tissue in the vault of the 
pharynx is the most prolific source, not only of acute and subacute 
catarrhal attacks, but finally of the development of chronic catarrhal 
middle-ear disease. 

We find, therefore, the chief etiological factors to be (1) chronic 
inflammations and obstructive lesions of the nose and nasopharynx 
extending to the middle ear through the Eustachian tube (diseased 
lymphoid tissue, hypertrophied tonsils, hypertrophied turbinal 
bones, deflected septa, and chronic pharyngitis) ; (2) chronic tubal 
catarrh extending to the tympanic cavity ; (3) recurring and per- 
sistent acute inflammations of the rhinopharynx. 

Pathology. — The mucous membrane of the tympanic cavity is 
changed in character because of an addition to its connective-tissue 
elements. The mucous membrane of the Eustachian tube is 
similarly affected. The mucous membrane usually becomes thick- 
ened, and in addition there is a tendency toward the formation of 
adhesive bands. In the Eustachian tube there is a tendency toward 
stricture because the apposed walls of the tube, especially at the 
tubal isthmus, become eroded, and adhesions take place. Finally, 
(186) 



CHRONIC MIDDLE-EAR CATARRH. 187 

a thick glairy mucous exudate may cover the membrane. This 
latter is often absent. 

Symptomatology. — The development of the disease is slow and 
insidious, and until some marked symptom such as tinnitus or an 
appreciable deafness appears patients may be entirely unaware of 
its existence. Pain or fullness of the ears usually occurs only during 
the acute exacerbations. Slight indefinite sensations of pain also 
occur during the intercurrent subacute exacerbations. The two 
most prominent symptoms are a gradually increasing deafness, and 
tinnitus. The tinnitus does not always appear early in the disease, 
but when it is present it clearly indicates to the individual that 
some functional intratympanic disturbance exists. It is usually 
intermittent, but may become constant and evoke great discomfort 
and nervous depression. 

There is no uniformity in the decrease in the hearing power. 
Extensive changes may take place in certain localities unattended 
by a marked decrease in audition. On the contrary in localities 
essential to the hearing faculty comparatively slight tissue changes 
may seriously interfere with the hearing function. The disease 
shows a tendency to progress more in a series of consecutive exacer- 
bations than as a steady progressive advancement. The loss of hear- 
ing frequently shows varying- modifications, one of the chief being 
paracusis Willisii, or a manifest increase of the hearing power in the 
presence of extreme noises. This has been described by Roosa and 
others as "boilermakers' deafness," the phenomenon being explained 
by some writers as resulting from more or less rigidity of the 
ossicular chain, with contraction of the tensor tympani muscle. 
This peculiarity of hearing is always indicative of a rather grave 
form of the disease, with an unfavorable prognosis. Occasionally 
individuals complain of painful sensations when in the presence 
of loud noises (dysacousia, dysacousis). Deafness may be either 
unilateral or bilateral during the early stages, but eventually both 
ears succumb to the catarrhal process. When the tissue changes 
have resulted from a former purulent process the affection may 
remain unilateral. At any stage the deafness is aggravated by 
physical exhaustion, worry, damp weather, and the impairment of 
the general health. 

A common symptom is described as a sensation of fullness and 
intratympanic pressure which is due to the partial closure of the 
Eustachian tube. The discomfort is marked. In other instances 
certain sounds are heard with more clearness than others. Some- 
times this is the human voice, and at other times metallic clicks or 
noises in general, while the human voice seems to be more or less 
indistinct. The patient's own voice at times appears to him altered 
either in pitch or in character, often sounding extremely loud, or, on 
the contrary, is heard with extreme difficulty and as though coming 
from a long distance; the latter symptom is termed autophony. 
Patients usually hear better and feel freer from their symptoms 
during clear, dry than during moist, humid weather. 

Other subjective symptoms, such as the hearing of sounds 



188 THE MIDDLE EAR. 

twice repeated or echoed, with alterations in intensity or pitch, are 
km iwn as paracusis duplicata or diplac'usis. These symptoms are more 
easily defined when but one ear is involved and when the patient is 
musically educated, as then the normal pitch as distinguished in 
the healthy ear will be found altered when the same fork is applied 
to the diseased one. This has sometimes been termed false hearing, 
especially when the alterations are sufficient to be a source of dis- 
comfort and annoyance to the patient. The term "false hearing" 
or "pseudoacousma" is applied to this symptom when it is extremely 
well marked. 

Tinnitus. — Tinnitus is variable both in constancy and charac- 
ter; hence, it becomes most difficult to adequately describe it. Tin- 
nitus is a marked symptom of labyrinthine disease and of various 
intracranial affections. The tinnitus of chronic catarrhal otitis 
media is rather superficial and the patients do not usually refer 
to it as deep-seated or within the head. It may partake of a ringing, 
clicking character, or it may sound like the escape of steam, or the 
humming of seashells. In the acute and subacute stages of the 
disease the clicking variety of tinnitus often indicates an obstruction 
of the Eustachian tube of sufficient density to demand energetic 
measures of relief. This refers to strictures and adhesions. Tinni- 
tus many times is the first and only- symptom complained of by 
patients suffering from chronic catarrhal otitis media even before 
the loss of hearing is sufficient to interfere with audition in any 
marked way. The tinnitus is usually more marked at night and 
under appropriate treatment it may subside or disappear altogether. 
The proportion of people in general who suffer from tinnitus and 
from partial or complete one-sided deafness is comparatively large, 
and many times a severe attack of tinnitus is the first warning of 
approaching deafness. 

At times vertigo, with or without disturbance of equilibrium, 
becomes a symptom of chronic catarrhal otitis media, although 
as a rule aural vertigo results from some diseased condition in the 
labyrinth. When present the vertigo is usually attributed to altera- 
tion of intralabyrinthine pressure, and it is believed that this may 
be brought about as the result of pressure upon the stapes and 
the round window by an accumulation of fluid in the tympanic 
cavity. The slight vertigo occurring as the result of chronic otitis 
media must not in any way be associated with those forms of 
vertigo ordinarily described as aural vertigo and Meniere's symptom- 
complex. 

Symptoms of intratympanic pressure are occasionally of suffi-' 
cient severity to give rise to actual unilateral headache. All these 
symptoms in the later stages, especially in hypersensitive subjects, 
manifest a decided tendency to the production of nerve depression 
and despondency. 

The Otoscopic Picture. — Marked changes in the drum mem- 
brane are not always indicative of relatively extensive changes 
within the tympanum, nor do they necessarily impair the hearing 
function ; on the other hand, extensive intratympanic changes, and 



Chronic middle-ear catarrh. 189 

much diminution of audition may be present with a comparatively 
healthy looking and normal appearing drum. As a rule, however, 
in such, cases the drum will be found to have lost some of its normal 
lustre, and unless atrophic changes have taken place other evidences 
of thickenings or adhesions will be found in at least certain portions 
of its surface. From the nature of the disease, interfering as it does 
with the function of the Eustachian tube, retraction of the drum 
membrane is to be expected (Fig. 111). In the earlier stages the 
gross appearance reveals, in addition to the retraction, more or less 
congestion, which is most marked along the manubrium (Fig. 
105). Not infrequently the retraction becomes so marked as to 
change the normal position of the handle of the malleus by forcing 
it inward sometimes until it comes into contact with the prom- 
ontory (Fig. 112). Under these circumstances the handle of the 
malleus appears foreshortened, occasionally to such a degree as to 
appear almost horizontal. 





Fig. 111. — Drum mem- Fig. 112. — Malleus handle 

brane retracted. foreshortened. 

The light reflex will be found to be altered from the normal 
(Fig. 112). Often the reflex is double and the color of the drum 
is usually paler than normal unless it is so thin that the reddened 
mucous membrane within is seen through it. The retraction of the 
drum membrane brings the short process and often the malleus 
handle- into sharp outline. The appearance of the pathological 
anterior and posterior folds is pathognomonic. 

In certain cases during the later stages, when the patient has 
been subjected to over-inflation, the drum will be found relaxed, a 
multiple light reflex being indicative of this condition. 

' Atrophy is usually present during some of the stages, and as a 
result the translucency of the drum reveals to the eye the outlines 
of the promontory, the descending process of the incus (Fig. 113). 
the incudostapedial articulation, and occasionally the crura of the 
stapes. 

As the lesion gradually progresses evidences of infiltration in 
the form of opacities make their appearance. These usually first 
appear in the form of crescents near the periphery (Fig. 112) ; occa- 
sionally, however, patches of opacity appear near the umbo. The 
light reflex becomes less marked, less regular in form, and may 
finally disappear altogether. Occasionally a light reflex may be 



190 



THE MIDDLE EAR. 



observed in almost any portion of the drum. Calcareous deposits 
in the drum of varying sizes and shapes are occasionally seen 
(Fig. 114). 

\\ henever contraction of Shrapnell s membrane takes place 
the short process becomes apparently more prominent, with a 
marked depression above (Fig. 36). Sclerosis of the drum may in 
time become so extensive as to finally result in the obliteration of 
the smooth, glistening, external surface, and also to completely 
obscure the outlines of the malleus handle, at the same time causing 
the anterior and posterior folds to disappear. 

The outlines of the old but healed perforations sometimes 
observed bear evidences of former suppuration (Fig. 115). 

Examination of the membrana tympani is never complete until 
its mobility has been determined. For this purpose some form of 
suction apparatus is employed to determine just what portion of 



EG 




Fig. 113. — Atrophic 
drum membrane, show- 
ing shadow of the long 
process of the incus, the 
incudostapedial articu- 
lation and the round 
window. 



Fig. 114.— Retrac- 
tion of the drum 
membrane with cal- 
careous plaques. 



Fig. 115.— Large 
perforation healed 
over with a thin 
layer of tissue. 



the drum is held down by adhesions. The manubrium should also 
be carefully tested in the same manner and its mobility determined. 
The tension of the drum at such examination should be compared 
with that which obtains under normal conditions, and both rare- 
faction and compression of the air in the external auditory canal 
are necessary to properly ascertain these data. Normal mobility 
may be present over certain areas and absent in others, and deep 
depressions may be found at spots where the firmest adhesions 
have taken place (Fig. 116). 

The actual conditions present in the Eustachian tube are ascer- 
tained by inflation, catheterization, the employment of the auscul- 
tation tube and the bougie. The patency of the Eustachian tube is 
not always clearly shown by the appearance of the drum membrane 
after Politzerization, but the character of the sounds produced 
when air is forced into the Eustachian tube through a catheter and 
transmitted to the ear of the observer has marked diagnostic value. 
Under normal conditions a soft, smooth, low-pitched, blowing noise 
is heard, indicative of a patulous and unobstructed tube. When, 



CHRONIC MIDDLE-EAR CATARRH. 



191 



however, a high-pitched, rough or crackling sound is heard, or if 
the bruit is obscure or almost entirely absent, some form of tubal 
obstruction is present. Tubal obstruction when unassociated with 
extensive tissue changes in the tympanic cavity is considered 
favorable so far as restoration of hearing is concerned, while 
marked patency of the tube with advanced deafness indicates an 
unfavorable prognosis. 

A variety of functional tests (see Chapter IV) to determine the 
character and extent of deafness are employed ; some of these give 
definite diagnostic data, and others are useful for differential 
diagnostic purposes. The tests recommended and outlined in the 
examination chart (Fig. 9) will usually be found sufficient for prac- 




Fig. 116. — Lateral view of the tympanic cavity, with key plate, partly 
schematic. The drum membrane is much retracted (1) and the 
inferior segment (2) is held firmly adherent to the internal tympanic 
wall by inflammatory adhesions (3). 



tical purposes and a diagnosis is possible by the employment of a 
few simple tests. It is advised that tests for distance be tried first. 
By the employment of the whisper and the acoumeter, the latter 
being more positive, the tests for distance are sufficiently covered. 
The watch and the spoken voice may be added. Of these three 
methods the acoumeter is preferred, as neither the intensity nor the 
character of the sound produced by this instrument ever varies, a 
condition which does not obtain when employing the voice or the 
watch as a test. 

Functional tests should be made at the first visit, before infla- 
tion is attempted. When one ear only is involved, or even in bilat- 
eral cases where marked difference in the hearing distance is 
present, the Weber test, in which a vibrating tuning fork placed 
either upon the vertex, the forehead or the teeth is heard best in 
the affected ear, suffices to establish a deafness due to interference 
with the conducting apparatus, except, perhaps, in those rare cases 



192 THE MIDDLE EAR. 

where, late in the course of the disease, impairment of the auditory 
nerve has taken place. 

The other tests, the Rhine, the Schwabach, are then carried out. 
For details of these see Chapter IV. 

Diagnosis. — Diagnosis of chronic middle-ear catarrh therefore 
depends on the history of progressive deafness and tinnitus, of 
periodical attacks of tubal catarrh, of an otoscopic picture showing 
retraction and sclerosis of the membrana tympani with occasional 
atrophic areas, changes in the character and position of the light reflex, 
and occasionally calcareous deposits. Confirmatory evidence is fur- 
nished by the employment of the hearing tests already referred to. 
(For description of the Holmes nasopharyngoscope, see Fig. 116a.) 

Differential Diagnosis. — The disease should be differentiated 
from otosclerosis, an affection which is characterized by progressive 
deafness, running its course without evidence of catarrhal symp- 
toms, and independent of those contributory factors found in 
the nose, throat and Eustachian tube. "Affections of the labyrinth 
differ from chronic catarrhal otitis media in the characteristic 
symptoms of vertigo and deep-seated tinnitus and in loss of the 
bone conduction of sound, the latter alone indicating disease of the 
sound-perception apparatus. 

Prognosis. — The prognosis in chronic catarrhal otitis media 
depends upon the nature and location of the tissue changes, the age 
of the patient, the degree of deafness present, and the chronicity of 
the disease itself. The disease promises a more favorable prognosis 
during the early or hypertrophic stage, also when occurring as the 
result of pathological conditions in the nose and nasopharynx, and 
finally when the disease is largely confined to the limits of the 
Eustachian tube. Timely institution of rational treatment in the 
earlier stages renders the prognosis more favorable. The return of 
normal or nearly normal hearing may be expected after restoration 
of normal conditions in the nose and nasopharynx, as a result of 
removal of diseased lymphoid tissue from the pharyngeal vault, 
of diseased or hypertrophied turbinate bones or deflected septa, the 
radical treatment of suppurating accessory sinuses, and by the 
maintenance of normal tubal conditions. 

Tntratympanic adhesions, extensive sclerosis, and prolonged 
and unvarying deafness, especially wdien occurring with but slight 
tubal involvement or intranasal disease, are conditions which render 
the prognosis unfavorable. 

Symptoms of commencing labyrinthine involvement are always 
to be regarded unfavorably, and little improvement is to be expected 
from any form of treatment in the way of amelioration of deafness 
in such cases. 

Treatment. — The treatment of chronic catarrhal otitis media 
should be based not only upon the visible signs exhibited upon 
examination of the membrana tympani, the nose and nasopharynx 
and the Eustachian tube, together with a complete series of func- 
tional tests, but also upon a complete general physical examination 
of the patient, together with a proper supervision of his habits, 




A 



Fig. 116e. 



Fig. 116a. — The nasopharyngoscope devised by Holmes 1 and illus- 
trated above marks a distinct advance in the examination, diagnosis, and 
treatment of affections located in and around the pharyngeal orifice of the 
Eustachian tube. By introducing the 'scope into the nostril opposite the 
tube which is to be inspected, one is able to obtain a satisfactory view of 
the entire orifice and surroundings. The illustrations, kindly loaned by 
Holmes, are significant of the usefulness of this instrument. The instru- 
ment is also available for examining the orifices of the sphenoidal sinuses 
and, in some instances, those of the posterior ethmoidal cells. Further- 
more, it may be employed in examining the larynx. 

Fig. 116&. — Pharyngeal opening of a normal Eustachian tube. 

Fig. 116c. — Anatomically constricted tube. (Chronic epipharyngitis 
and salpingitis J 

Fig. 116c/. — Papilloma attached to the posterior superior wall and 
about one-third inch from the orifice of the tube. 

Fig. 116c. — Two adenomatous polyps arising within the tube. Both 
turbinals, much hypertrophied, resting upon the anterior lips of the tube 
and in contact with the growths within the lumen of the tube. 



Trans. A. L. R. 



uid O. Society, 1911, page 



190. 



CHRONIC MIDDLE-EAR CATARRH. 193 

occupation, and mode of life. Should examination bring to light 
any organic disease, either of the nervous, circulatory or glandular 
system, or those of a more general character, such as tuberculosis, 
syphilis, diabetes, Bright's disease, rheumatism, gout, or digestive 
affections, appropriate and vigorous treatment must be instituted 
to combat the condition found. Proper habits of rest and exercise 
should be insisted upon, and excesses, especially in the use of 
alcohol and tobacco, interdicted. 

The author has repeatedly proven by observation and treat- 
ment of hundreds of cases, especially in early life, that intranasal 
pathological conditions and deformities have exercised a marked 
influence upon the middle ear. Diseased lymphoid tissue (adenoid 
vegetations or hyperplasia of Luschka's tonsil) ; malformations and 
hypertrophies of the inferior turbinate bone ; cystic enlargement of 
the middle turbinate bone, with or without polypi (ethmoidal sup- 
puration) ; deflection of the cartilaginous and bony septum, and 
chronic atrophic rhinitis all predispose to chronic catarrhal otitis 
media. In children with extensive lymphoid (adenoid) tissue in 
the pharyngeal vault an almost constant state of middle-ear inflam- 
mation is maintained, as may be observed from the congested 
appearance of their drum membranes. Hence, as a preliminary 
to any direct treatment of the ear all pathological conditions in the 
nose and nasopharynx must be corrected, and no intratympanic 
treatment may be considered as effective and thorough until the 
nose and nasopharynx shall have been rendered comparatively 
healthy. 

Of the methods employed for the restoration of normal condi- 
tions in the Eustachian tube, we briefly refer to the following: 
Those already described relating to the restoration of normal condi- 
tions in the nose and nasopharynx. In the simpler forms of Eusta- 
chian catarrh intranasal treatment alone will suffice to effect a cure. 

When the disease has been long continued or of sufficient 
severity to result in infiltration, with thickening of the mem- 
branous lining and consequent diminishing of the calibre of the 
tube, much may be accomplished either by simple inflation, the use 
of the catheter, or the introduction through the catheter of vapor- 
ized medication or superheated air. 

These tend to promote absorption of exudate and to maintain a 
healthy state of the mucous membrane. Of these methods cathe- 
terization with sufficient persistency, or catheterization plus the 
introduction of medicated vapors, remain the two most effective 
methods of procedure. Inflation by means of the Politzer bag is 
usually less effective than catheterization, and is attended with 
more or less danger of over-inflation, inasmuch as the method is less 
controllable than when the catheter is employed. 

The employment of medicated vapors, notably the combination 
of camphor, menthol and iodin, equal parts, by means of the 
Dench vaporizer (Fig. 21), is of considerable efficiency, and, while 
it must be admitted that but little of the remedy actually reaches 
the surfaces of the tube, yet sufficient is introduced to exert con- 
is 



194 THE MIDDLE EAR. 

siderable influence upon its mucous lining. The technique of 
catheterization is described in Chapter II. Air-douche therapy is 
described in Chapter VIII. 

The author is a strong advocate of the employment of the 
Eustachian bougie in all rebellious cases of tubal obstruction. It is 
in no wise a "cure-all," but in many cases the relief of tinnitus and 
increase in hearing, which follows the introduction of the bougie, 
are gratifying. The tinnitus may never recur and some degree of 
the increase in hearing may be permanently maintained. Should 
either the tinnitus or deafness recur after a few weeks or months, 
relief may again be effected by means of a reintroduction of the 
bougie. Among the author's patients are those who appear at 
regular intervals of from one to six months "to be bougied," claim- 
ing to receive much benefit from the procedure. With rare excep- 
tions the whalebone bougie fulfills all the requirements. 

The electric bougie advocated by Duel may be employed when- 
ever the stricture proves impermeable to the whalebone bougie. 
It is a complicated procedure, requiring a galvanic current, and 
insulated gold bougie. The technique is difficult, and in a few 
instances reported portions of the distal extremity of the bougie 
have broken off while in the tube. Nevertheless, the electric bougie 
can be made to overcome strictures which are impermeable to other 
forms. For the technique of passing the bougie see Chapter II. 

Occasionally a tube will be encountered which is impermeable, 
with all the attendant aggravating symptoms of extreme deafness 
and tinnitus. Fortunately this occurrence is rare and, in these 
cases, treatment is usually without avail. 

Otomassage (For full description see Chapter VIII). — Oto- 
massage is of sufficient merit in the treatment of chronic catarrhal 
otitis media to deserve a brief mention. It is employed to prevent 
adhesions within the tympanic cavity, to break down those already 
formed, and to relieve tinnitus. The use of the pressure-sound for 
the purpose of massage is painful, and of doubtful efficiency. 
Vibratory massage relieves tension and usually lessens the severity 
of tinnitus and produces a marked soothing effect upon the nerves 
of those who are depressed and despondent. 

AYhenever intratympanic adhesions exist, especially those 
involving the stapes on the one hand and the round window on the 
other, a more or less severe deafness is present. Adhesions may 
form in almost any locality. The membrana tympani may be 
found retracted and attached to the walls of the tympanic cavity ; 
occasionally the long process of the malleus may be found adherent 
to the promontory — in fact, a variety of results of adhesive inflam- 
mation may be present. But little may be accomplished for the 
relief of adhesive inflammations. The results obtained come chiefly 
from intratympanic inflation, or some form of forced manipulation, 
such as may be secured from the use of the Siegel otoscope or 
electric massage. The adoption of these methods may result in 
considerable relief to tinnitus, with occasional cessation of the 



CHRONIC MIDDLE-EAR CATARRH. 195 

tendency to progressive deafness and sometimes slight betterment 
of hearing. 

A number of drugs have found employment in the treatment 
of these cases. Among' these the one which has given the most 
promising results is thiosinamin. Theoretically, the properties of 
this drug make it an ideal one to influence the absorption of new 
connective tissue. Practically, however, we have no exact evidence 
of its usefulness. One can use it in combination with inflations, or 
separately. It is generally given hypodermatically in doses of gr. 
y 10 to Y 5 . - Fibrolysin has lately been recommended for the same 
purpose by E. Urbantschitch. 

Finally, in desperate cases, operative measures are occasionally 
resorted to in order to relieve the adhesions and improve the 
hearing. These operative measures consist in making a flap from 
the accessible drum membrane, and, through the opening thus 
made, explore the intratympanic space. The adhesive bands are 
then severed. 

The incision is usually made with a small bistoury, and the 
adhesions are severed with an angled knife, introduced through the 
first incision. 

Occasionally, it is necessary to cut the tendon of the tensor 
tympanic muscle. The drum being incised, an angled knife is 
introduced so that its edge impinges upon the muscle tendon, the 
blade being pushed along the back of the malleus handle. A slight 
pressure severs the muscle. The tensor tympani is reachable from 
either in front or behind the malleus handle. 

The stapedius muscle is sometimes also cut. Although this 
operation was formerly performed, it has now fallen into disuse 
because no good effects are obtained. 

Complete ossiculectomy (see Chapter XXI), performed to sever 
adhesions and improve hearing in this class of cases, has never 
given good results. 



CHAPTER XVIII. 

DISEASES OF THE MIDDLE EAR. 
{Continued.) 

ACUTE INFLAMMATION OF THE MIDDLE EAR AND 

MASTOID PROCESS. 

(Acute Purulent Otitis Media.) 

Introductory. — Acute inflammation of the middle-ear spaces is 
characterized by a bacterial invasion of these spaces, resulting- in 
the production of a purulent exudate from the mucosa of the 
tympanic cavity. The outpour of exudate gradually accumulates 
until it completely fills the tympanum, thereby causing a swelling 
of the lining mucosa of the entire cavity and Eustachian tube. 
This, in turn, finally occludes the Eustachian tube, bulging of the 
drumhead ensues, and later, if not' artificially relieved by a para- 
centesis, spontaneous rupture of the drumhead takes place. If the 
disease progresses it spreads by contiguity through the aditus into 
the mastoid antrum, and finally involves the mastoid cells, a com- 
plication which is termed acute mastoiditis. Various complications 
characterize the advanced stages if the disease remains unrelieved, 
the details of which we shall describe later. 

Pathology. — The early stages of acute purulent otitis media 
are not sharply definable clinically from some of the catarrhal 
forms. 

The inflammatory involvement of the Eustachian tube results 
in an obliteration of its lumen. The determining factor of the 
disease is the invasion of micro-organisms. These grow in the 
mucoserous fluid which obtains in the tympanic cavity, resulting 
in the formation of a purulent exudate. 

The lining mucosa of the tympanic cavity meanwhile becomes 
swollen and thickened, and the mucous lining of the membrana 
tympani becomes likewise involved. Hence its red and thickened 
appearance at this stage. As the purulent exudate increases in 
amount, it reaches the upper chambers of the tympanic cavity and 
the aditus becomes affected. Following the line of least resistance 
the exudate flows into the mastoid antrum, which gradually 
becomes filled and the neighboring cells gradually involved until, 
in a case which progresses to its ultimate end, all the cells become 
infected. As the pus in the cells increases in amount it exerts 
undue pressure upon the mucosa and the intracellular walls, and 
their nutrient blood-supply is finally shut off with the inevitable 
result that these walls become necrosed, coalescing one cell into 
another, until in the advanced stages one often finds nearly the 
entire mastoid process converted into one large bony pus cavity, 
with areas of the inner table of the mastoid process broken through 
and the underlying vital structures exposed. 
(196) 



INFLAMMATION OF MIDDLE EAR. 197 

One is often surprised that the accumulation of pus under 
pressure within the mastoid cells does not more frequently break 
through the thin roof of the antrum. It often does break through, 
but more commonly it invades the entire mastoid process first. 
Explanation for this on a pathological basis is found in the excellent 
blood-supply of the tegmen tympani, tegmen antri, and tegmen 
cellulae through the blood-vessels of the dura mater, which acts to 
these structures as their periosteal coating. 

Bacteriology. — It is now generally conceded that the micro- 
organisms almost invariably find their way into the tympanic 
spaces through the Eustachian tube. The character of the invad- 
ing organism and its virulence are potent factors in determining 
the clinical picture; this together with the variations in degree of 
the resisting power of individuals explains the difference in the 
course and termination of the attacks. In one case resolution will 
follow incision and drainage of the middle ear, while in a second 
case cure is not effected until the mastoid process is opened. 

Secondary infections occasionally enter the tympanic cavity 
through a perforation in the drumhead, and many observers con- 
tend that a tuberculous invasion may also enter the tympanic 
cavity by way of the lymph channels and the blood-streams. 

The bacteriology of the ear discharges forms a part of the 
chapter on General Etiology, page 43. 

■Etiology. — The causes of purulent middle-ear affections are 
grouped as predisposing and inciting. 

The predisposing factors to middle-ear diseases are to be sought 
for among those irritants in the upper respiratory tract which 
interfere with the physiological play of the cilia on the cells lining 
the walls of the Eustachian tube. Among such, rhinopharyngeal 
abnormalities are prominent, as is also hereditary taint, and the 
presence of general debilitating diseases, as, for instance, diabetes. 

The inciting causes, heretofore mentioned under the pathology, 
are found in the invasions of the middle-ear cavities by large num- 
bers of micro-organisms which develop their characteristic lesions 
over various areas of the intratympanic mucosa. The source of 
the invading micro-organisms is the infections commonly found in 
the nose and nasopharynx, which, in turn, are usually the result of 
specific infections, such as the exanthemata, epidemic influenza, etc. 

Out of 6000 cases of scarlet fever, measles and diphtheria, 
treated at the Willard Parker Hospital, collated by Duel, 20 per 
cent, of the scarlatina cases, 10 per cent, of the diphtheria cases, and 
about 5 per cent, of the measles cases developed purulent otitis 
media. There were 26 mastoid cases, nearly all of which occurred 
in cases with combined infection. In children under five years 
postauricular swelling was common, which he believed to be the 
result of the escape of pus through theJRivinian fissure. 

Incidentally, various oilier factors tend to influence and aggra- 
vate the purulent proeess in the middle ear, such as bad habits, 
excessive alcohol, neuroses, etc. 



198 THE MIDDLE EAR. 

Finally, trauma is in etiological relationship to acute purulent 
middle-ear disease, when either by direct violence or by indirect 
violence the drum is ruptured, and the middle-ear spaces are thus 
laid open to bacterial invasion. 

In mentioning some of these factors more in detail, we note" 
that trauma often results in more or less severe inflammation of the 
tympanic cavity, and, when no efforts are made to prevent infection, 
the inflammation eventuates in purulency. Traumatism from 
bullets or other penetrating objects, by destroying smaller or 
greater areas of the middle ear not only directly destroy the 
parts, but, By subsequent infection, cause middle-ear suppuration. 

In children carious teeth may indirectly become a source of 
middle-ear infection, and unless corrected these may continuously 
breed micro-organisms which constantly invade the tympanic 
cavity. 

Another factor of etiological moment in the causation of 
middle-ear inflammations is commonly observed during the summer 
season, the attack following a sea bath, or a swim in fresh water. 

Here evidently the water, contaminated with bacteria from the 
nasopharynx, is forced into the tympanic cavity through the Eusta- 
chian tube because of faulty breathing while swimming or diving 
or by forcibly blowing the nose, and once having gained entrance 
it acts as a foreign-body irritant. Later on the bacterial invasion 
evokes a purulent exudate. In newborn infants the same thing 
occurs, when, during parturition, amniotic fluid is forced through 
the short, straight, open Eustachian tube. This form of otitis has 
been termed otitis media neonatorum. 

The presence of adenoid tissue in the vault of the pharynx, 
hypertrophied tonsils, intranasal obstruction of various types, 
furnish examples of respiratory lesions which indirectly induce 
middle-ear infection. Obstructed nasal breathing from whatever 
cause is injurious to the middle ear, while diseased lymphoid tissue 
in the vault, or even in the tonsils, must retard intratympanic 
aeration. The masses of lymphoid tissue, however, on account of 
their peculiar structure, become seriously menacing during the 
course of acute infections of the mucosa of the nose and naso- 
pharynx, inasmuch as they both retain infectious material, and by 
becoming swollen and obstructive they facilitate the entrance of 
infection in the Eustachian tube. It may be stated definitely that 
diseased lymphoid tissue in the pharyngeal vault is a most prolific 
indirect cause of purulent middle-ear disease. The writer has never 
seen a case of recurrent middle-ear suppuration, especially in child- 
hood, unaccompanied by a greater or lesser development of lym- 
phoid tissue in the vault of the pharynx. 

Hypertrophied and diseased inferior turbinals, by obstructing 
the chief channel for the entrance of air. often show a marked 
tendency to aggravate middle-ear inflammations. Cystic and 
polypoid middle turbinals tend also to produce the same result. 
A more or less completely deflected septum, interfering as it does 



INFLAMMATION OF MIDDLE EAR. 199 

with nasal respiration, likewise aggravates the symptoms of middle- 
ear inflammations. 

Tumors, whether malignant or otherwise, acting directly as a 
result of obstruction or indirectly by lowering the vitality, must 
also be considered. 

The vascular and lymphatic systems with which the mechanism 
of the middle ear is so liberally supplied, necessary as they are to 
its proper maintenance, as well as for the proper control of its 
functions, and working so perfectly as they do under proper condi- 
tions of health, may become a serious menace when influenced by 
diseased conditions either local or general. That infection reaches 
the middle ear through these channels has been definitely proven, 
especially as regards the tuberculous variety. 

Changes also in the tissues which enter into the make-up of the 
tympanic cavity are undoubtedly directly influenced by derange- 
ments in the character and normal functions of the blood-vessels 
and lymphatics. 

Systemic diseases, such as diabetes, gout and rheumatism, and 
those resulting from the improper use of medications, intoxicants 
or narcotics, by acting upon the vascular system in general, also 
affect, to a marked degree, the tissues of the tympanic cavity. 

All infectious diseases, from their very nature and because of 
the fact that the membranes of the upper respiratory passages are 
thereby involved, possess a marked tendency to involve the tym- 
panic cavity. The routes by which these infections travel have 
already been described. Measles, diphtheria, typhoid, scarlet fever, 
parotiditis, grippe, and other forms of infectious colds and inflam- 
mations, furnish a supply of their peculiar pathogenic micro- 
organisms, and the middle ear is never free from danger while 
such infections exist. 

Of the more chronic forms of infection those involving the 
accessory sinuses of the nose are quite prolific in the causation of 
purulent otitis media. The author has repeatedly observed cases 
of violent purulent otitis media that could be directly traced to the 
forced introduction of the discharges from the accessory sinuses 
through the Eustachian tube into the tympanic cavity. 

Tuberculosis and syphilis, on account of their frequent occur- 
rence, warrant special mention. The manifestations of tuberculosis 
are always those of ulceration and destruction of the membrana 
tympani and also of the intratympanic structures. 

The infection may, and probably does, enter the cavity through 
the Eustachian tube with comparative frequency, but it may also 
extend from tuberculous glands or other forms of tuberculous infec- 
tion directly through the lymphatics. 

The question as to the route by which tuberculosis reaches the 
middle ear and mastoid lias aroused endless discussion; various 
observers, even when basing their opinions upon autopsy findings, 
hold diametrically opposite views. At the present stale of our 
knowledge we may say that the middle ear becomes involved not 
only by the Eustachian-tube route and the lymphatic channels, but 



200 THE MIDDLE EAR. 

also directly through the blood-vessels. The reader is referred to 
Part II of this work (The Influence of General Diseases upon the 
Ear, Nose and Throat) for details and statistics relating to infec- 
tion of the middle ear from the various general infectious diseases. 

Manifestations of syphilis in the tympanic cavity are extremely 
rare, being found only when a broken-down gumma appears in 
this locality. 

Symptomatology and Course. — The onset of an attack of acute 
purulent otitis media is usually sudden, following a "cold," an 
attack of grippe, or during the later stages of one of the exanthe- 
mata. There is usually a prodromal stage lasting a few hours, 
during which the ears feel "full," the patient's voice sounds unduly 
loud (autophony) and he thinks there is some obstruction in the 
external ear. The most significant symptom is the excruciating 
pain, which persists without cessation until relieved by rupture of 
the drum membrane. The onset oi pain is simultaneous with the 
filling of the tympanic cavity with pus. In children the onset is 
often marked by chill and a considerable rise in temperature. 
Among those just having passed through an attack of measles or 
scarlet fever, a rise in temperature alone, if unaccounted for other- 
wise, is gravely suggestive of ear involvement. Among adults 
fever is not a usual sign. Convulsions are common among young 
children — in fact, symptoms which would seem to indicate menin- 
geal irritation are commonly observed in very young infants, all of 
which subside as soon as the drumhead is incised. Furthermore, 
in these young patients, among the early stages, a diarrhea may 
develop which is prone to mislead the attending physician. 
This symptom must be borne in mind by those in attendance upon 
infants and young children. 

Pain. — The earache soon becomes intense. It is throbbing, 
lancinating, boring and not intermittent in character, although 
often found to be less in the morning than at night. With the 
advent of the otorrhea, through either spontaneous rupture of the 
drum or incision by the surgeon, the pain rapidly ceases. Infants 
are unable to give expression to the suffering except by crying, 
which often amounts to agonizing shrieks. They are restless, roll 
the head with a boring motion, and seem to rest best when held in 
the lap with the affected ear downward. It sometimes happens 
that 3^oung children develop virulent otitis media with but little 
pain, the pressure being sufficiently relieved by drainage through 
the Eustachian tube. Even after the otorrhea is established, the 
pain recurs if the flow is interrupted from any cause, such as a 
blocking of the perforation. 

Certain cases of acute purulent otitis media run their entire 
course without pain. These are first and foremost the tuberculous 
and syphilitic forms. 

Pain is also absent in cases where from the very beginning for 
some cause a perforation is present in the drum. Since the pain is 
the result of pressure by the pus in the tympanic cavity, no pain is 
found in these cases because the pus is never under pressure. 



INFLAMMATION OF MIDDLE EAR. 201 

Examples of this type occur when an acute middle-ear inflammation 
takes place in an adult, who in early life had suffered from a 
chronic otorrhea with destruction of part of the drum membrane. 
The cessation of pain also marks the period in the infant when the 
meningeal irritative symptoms are wont to stop. That is with 
the establishment of the otorrhea. 

Fever. — The temperature deserves some special comment. In 
many cases, especially among- adults, it is entirely absent. In chil- 
dren and young- adults it lasts some days, ranging from 100° to 105° 
before the advent of the otorrhea, and often a few days thereafter. 
In these cases, where the temperature persists after the advent of 
the otorrhea, the question as to whether or not the disease has 
spread beyond the tympanic cavity becomes one for serious con- 
sideration. If the general status of the patient remains good, if the 
sensorium remains clear, and if the pain remains slight, and no 
tenderness appears behind the ear, there is no cause for alarm, nor 
is operative interference indicated. In children one should also 
carefully watch for glandular swelling, as a swelling at the angle 
of the jaw may mean a mastoiditis. 

It requires a certain time for the body economy to establish its 
lines of resistance to the invasion, and until this is established the 
temperature is likely to continue. 

Finally, the fever may continue because the original lesion, the 
rhinitis, pharyngitis, bronchitis, pneumonia (especially in children) 
or typhoid may not }^et have subsided. 

The Otorrhea. — The otorrhea begins usually from one to 
three days after the advent of the disease. In children the rupture 
of the drum may be delayed because there is an outflow of pus 
through the Eustachian tube. In rare cases the otorrhea begins a 
few hours after the commencement of the disease. On the one 
hand we may be dealing with an abnormally thin drum, or with a 
thickened drum from previous catarrhal attacks. 

At the commencement the otorrhea is mostly serous in char- 
acter, or serosanguineous ; generally it is profuse. Later it becomes 
thicker and more purulent. It contains the exciting micro- 
organisms in abundance. 

As the disease progresses, if toward resolution, under appro- 
priate treatment, it gradually subsides and in from three days to 
five or six weeks it disappears. 

In cases which resolve, with the cessation of the discharge, a 
cicatrization of the drumhead supervenes. The membrana tympani 
becomes paler and thinner; meanwhile the outline of the malleus 
becomes visible. The hearing gradually returns toward the normal. 
The accompanying tinnitus aurium, under treatment by inflation, 
gradually subsides and the hearing becomes normal. In cases which 
do not go on to resolution the infection extends, with involvement 
of the structure of the mastoid process, following which, if unre- 
lieved, intracranial, labyrinthine complications become imminent, 
or perforation of the mastoid cortex may supervene. A considerable 



202 



THE MIDDLE EAR. 



proportion of cases of this type terminate in the chronic form of the 
disease with necrosis, loss of hearing and cholesteatoma. 

Lastly, involvement of the facial and abducens nerves (Gra- 
denigo, 1904) may take place, or brain lesions may end the patient's 
life. 

Diagnosis. — Otalgia with otorrhea may arise from either otitis 
media or otitis externa. If the external auditory canal is not 
swollen and not painful to pressure, then the supposition exists 
that the patient has purulent middle-ear disease. If the external 
ear is filled with pus which pulsates, the diagnosis of an acute 
middle-ear purulency can be made, even if no otoscopic examination 
is possible. An otoscopic examination is not always possible in the 
very young. Severe pain, associated with intense redness and 
bulging of the membrana tympani are the characteristic early 
symptoms. 





Fig. 117. — Inflammatory en- 
gorgement of the blood-vessels 
of the membrana tympani. 



Fig. 118.— Bulging of the 
drum membrane. 



Otoscopic Examination. — Otoscopic examination will show a 
bluish red (Fig. 117) or very red swollen membrana tympani during 
the first stage, preceded by a short stage during which the 
blood-vessels are intensely engorged. Bulging, in whole or in part, 
soon appears (Fig. 118), with absence of light reflex and other 
normal landmarks (Figs. 118 and 119; also Fig. 120). If already 
perforated one sees a small puncture, irregular in outline (Fig. 
121), and the drumhead covered with desquamated epithelium so 
that its outlines are hardly recognizable. 

In severe cases the onset of the disease is characterized by 
the appearance of large blebs (hemorrhagic and serous) in the 
layers of the drum membrane (Fig. 122). 

Among children the slanting of the drumhead toward the 
horizontal renders the exact determination of the conditions present 
harder, and in addition the surgeon is occasionally hampered in 
his examination by narrowing of the canal lumen. 

When seen later in the course of the disease, there is distinct 
bulging in one or more segments of the drumhead (Fig. 123), and 
often a yellowish tinge to the drum due to the light shining on the 
pus behind the drum. Mastoiditis presents its own peculiar symp- 
tomatology, to which we will refer below under appropriate 
headings. 



INFLAMMATION OF MIDDLE EAR. 



203 



Prognosis. — Under favorable conditions in patients of other- 
wise good general health, when managed in accordance with 
approved modern methods which meet all the indications for treat- 
ment, the prognosis is good, both for cure of the otorrhea and a full 
recovery of hearing. The outcome is influenced unfavorably when- 
ever serious complications develop, and especially so in strumous, 
cachectic, tuberculous or syphilitic patients ; when some other 
grave constitutional disease is present ; in children who are victims 
of diseased lymphoid tissue in the pharyngeal vault, and when the 
treatment has been unskillful, uncleanly or faulty in important 
particulars. 

Repeated attacks of acute purulent otitis media are considered 
unfavorable, especially in their effect upon hearing. 





Fig. 119. — Lateral view of the tympanum, with key plate, partly 
schematic, showing bulging of the drumhead (1), pus in the tympanum 
(2), and absence of the usual prominence of the processus brevis (3). 



Treatment. — At the commencement of an attack of purulent 
otitis media, the patient should be placed in bed in a well-ventilated 
room of even temperature. 

These patients usually have an elevation of temperature ; 
furthermore, there is an infectious process going on in the tym- 
panic cavity, the progress of which is favorably influenced by rest 
and freedom from exertion, and the patient in bed is less apt to take 
cold, thus avoiding much of the danger of serious complications. 

Rest in bed, therefore, is of supreme importance, the length of 
time varying from two to three days to two weeks until the acute 
inflammatory symptoms have passed away, the temperature 
becomes normal, and the danger of complications has passed. 

A brisk cathartic at this time, preferably calomel, materially 
relieves congestion and produces a favorable effect upon the inflam- 
matory process. 

A varietv of remedies have been advocated for the relief of 



204 



THE MIDDLE DAK. 



pain during the early stages before rupture or incision of the drum 
membrane has taken place. Of these but two are worthy of men- 
tion, while many are productive of considerable harm. There is no 
better local method for relief of pain than by douching the external 
auditory canal with hot water (Chapter VIII, page 82). For this 
purpose a douche, bag filled with hot sterile water or a bichlorid 
of mercury solution 1:4000 or 1:5000 is used. The bichlorid of 
mercury accomplishes no other good than to sterilize a field which 
may have to be operated on later. 

The second measure recommended for relief of pain is opium. 
Under favorable conditions, in older children and adults, moderate 
doses of opiates often aid in tiding the patient over the period of 
excruciating pain which often precedes the time when sufficient 
indications for paracentesis appear. The instillation of oily prepa- 





Fig. 120. — Lateral view of the tympanum, with key plate, partly 
schematic, showing (1 ) bulging of drumhead. The tympanum is nearly 
tilled with pus (2), the long process of the malleus (3) is forced out- 
ward with the bulging drum and the usual prominence of the short 
process (4) is partially obliterated. 



rations into the external canal is invariably contraindicated, inas- 
much as the oily mass remains in the canal and becomes inter- 
mingled with the exfoliations of epithelium from the canal walls, 
thus forming a rancid mass which is most difficult to remove. 

Furthermore, this condition adds to the difficulties experienced 
in sterilizing the external meatus as a preliminary to incision of the 
drum membrane. Many authors have recommended the employ- 
ment of leeches during the preliminary stage of purulent otitis 
media, believing that the local bloodletting tends to abort the 
infective inflammatory process. The author does not fully hold 
this view, and deprecates the employment of the leech under any 
circumstances. His reasons for this are more fully outlined in 
Chapter VIII, page 96. 

In cases wherein there is extensive inflammatory infiltration 
in the early stages some relief from pain is obtained by local blood- 
letting, either by incisions in the canal wall or by the employment 
of artificial leeches applied about the insertion of the auricle. 

Incision of the Drum Membrane (Paracentesis). — The ex- 



INFLAMMATION OF MIDDLE EAR. 



205 



udative stage of the disease furnishes the indication for surgical 
interference in the form of an incision of the drum membrane. If 
no perforation is present, or if too small a perforation has taken 
place spontaneously, incision of the drum membrane becomes the 
first therapeutic indication. This little procedure, since its intro- 
duction into otology by Schwartze in 1867, has become one of the 
most useful surgical measures employed in otology. The technique 
of this operation is fully described in Chapter VII. 

The author's views as to the indications for incision of the 
drum membrane are as follows : — 

Paracentesis is employed principally for the purpose of evacuat- 
ing the purulent contents of the tympanum, the ultimate object 
being to relieve pain, limit the extent of the infection, shorten the 
course of the disease, and prevent complications. 




Fig. 121. — Lateral view of the tympanum, parti}' schematic, showing 
perforation in the lower segment of the drum membrane. 



Paracentesis of the drum membrane is indicated in acute 
purulent otitis media when attended with intense redness and 
bulging of the drum membrane, in whole or in part. With these 
objective symptoms there are coexisting pain and fever, the latter 
being more marked in young children. The syndrome above 
described, viz., bulging of the drum membrane — intense aural pain 
and fever, is invariably of sufficient import to warrant this opera- 
tion. In infants bulging is a later manifestation than in adults. 

Occasionally the purulent process may have continued for some 
days without rupture, especially in infants, in which event the 
intense redness gradually assumes a yellowish color, due to attenua- 
tion of the membrane and the accumulation of purulent exudate 
in the tympanic cavity. An early paracentesis, when performed 
under strict aseptic precautions, is preferable to a dela3 r ed spon- 
taneous rupture. It is a safe rule to open the drum membrane as 
soon as the diagnosis of purulent tympanitis becomes positive. 

A clean-cut incision in the drum membrane, and by this is not 
meant a puncture (Fig. S3), immediately relieves the pressure, 
establishes drainage, and the subsequent healing of the wound 
takes place with but little damage and no scar tissue. Nature's 



206 



THE MIDDLE EAR. 



opening is usually a small jagged hole, the borders of which are 
more or less necrosed, and as healing takes place it is prone tio 
result in scars, and considerable deposits of new connective tissue 
in the drum membrane. 

Paracentesis is also indicated for enlarging perforations which 
already exist, providing they are too small or are unfavorably 
located for purposes of drainage. A pinhole perforation in the 
presence of an extensive intratympanic purulent process affords 
insufficient drainage. These small perforations are usually accom- 
panied by a sensation of throbbing or pain in the ear or mastoid 
region. They do not entirely relieve the bulging of the membrane, 
especially at the site of the opening. In enlarging the pinhole 
perforation it is often necessary to cut both upward and down- 



k. 


?*v 


^01 


5kl 


J^r 


~Z? aSS c~ 



Fig. 122. — Lateral view of the tympanic cavity and drum membrane, 
partly schematic, showing extravasation of exudate between the layers of 
the' membrana tympani. 



ward, in order to establish drainage both of the tympanic and attic 
region. 

The operation releases pent-up pus from the tympanic cavity, 
and thereby retards the tendency to bacterial invasion of the con- 
tiguous structures, establishes free drainage of inflammatory 
exudate, shortens the course of the disease, and lessens the danger 
of mastoid, intracranial and labyrinthine complications. These 
results come chiefly from the rapid removal of the inflammatory 
products from the tympanic cavity, which otherwise might be 
forced under pressure through the aditus into the mastoid antrum. 

Relating more specifically to the disease under consideration 
it may be observed that any point of marked bulging of the drum 
membrane is the area through which the incision should pass. If 
the drum is generally bulging the posterior half of the drum is 
selected as the site of election. 

The incision is curved, paralleling the posterior periphery of 
the drumhead (Fig. 54). This severs both the radiating and the 
circular fibres in the drum and tends to cause the incised wound 
to gap and thus favors drainage of the tympanic cavity. Care 



INFLAMMATION OF MIDDLE EAR. 207 

should be exercised that the knifeblade does not impinge upon the 
ossicles, and the entire procedure must be characterized by gentle- 
ness. Experience has shown that just in these cases the drum- 
head is often very thick, and therefore the incision must be made 
long enough to cause a gaping wound. In children the horizontal 
slant of the drum may cause the inexperienced to either miss it 
altogether, or only make a slight incision because the lower parts 
(deeper-lying parts) are missed by the knife, therefore the blade 
must be introduced sufficiently deep to incise the entire extent. 

After-treatment. — Immediately after the incision a strong flow 
of exudate ensues, mingled freely with blood. The ear is now 
cleansed and a gauze drain placed into position for a few hours. 
It is well to allow the patient some rest immediately following 
paracentesis, because usually they have had severe pain and nervous 
strain for some time previously. Then later, after some hours, the 
regular treatment of the otitis begins. Sometimes it becomes 




Fig. 123. — Marked bulging of the posterosuperior quadrant of 
the drum membrane. 

necessary, because of recurrence of the symptoms and cessation of 
the discharge, to repeat the paracentesis. This should not be 
delayed when the symptoms show it to be indicated. The indica- 
tions to be fulfilled in the subsequent local treatment are: (1) 
cleanliness ; (2) free drainage. Cleanliness is best maintained by 
douching the external auditory canal with physiological salt solu- 
tion or solution of bichlorid of mercury, 1 : 3000. The quantity of 
fluid (which should be heated to about 110° F.) to be used should 
be from 1 to 2 quarts, and the treatment should be repeated every 
two hours. (For detailed information in regard to douching see 
Chapter VIII, page 82.) 

In order to guard against secondary infection efforts are 
directed to prevent the entrance of infection from the external 
meatus. This may be accomplished by loosely placing in the 
concha and external orifice of the canal a strip of sterile gauze, 
to be removed as soon as it becomes moist from pus and then 
replaced with a fresh piece. In young children, or whenever it is 
found difficult to maintain perfect cleanliness by this means, the 
whole ear should be protected by bandaging. Thus the require- 
ments above mentioned arc fulfilled. At least once in each twenty- 
four hours a careful ocular examination of the drum should be 



208 THE MIDDLE EAR. 

made to ascertain the size and character of the perforation, so as to 
enlarge it whenever it becomes too small to maintain drainage, 
likewise trie mastoid process should be examined to discover evi- 
dences of mastoiditis. The condition of Shrapnell's membrane and 
the posterior superior wall of the external auditory canal must 
always be carefully noted. At each visit firm pressure is made over 
the mastoid antrum, tip and posterior angle, and the condition of 
the nose and throat ascertained. Unless specially trained nurses 
are in attendance to carry out the local therapeutic measures, careful 
instruction should be given to those in charge, with an actual 
demonstration of the treatment administered at each daily visit, in 
order to insure the proper care of the patient. 

Inasmuch as this affection is rarely unaccompanied by naso- 
pharyngeal infection, it becomes necessary to instigate proper 
intranasal treatment at the very onset, in order to remove accumu- 
lations of infected secretion and relieve the attendant inflammation 
of the mucosa. Non-irritating sprays, both aqueous and oily, aid 
in bringing about the required result. Such treatment should con- 
sist of non-irritating alkaline sprays for cleansing and medicated 
oily sprays or mildly astringent applications to the mucosa, 
employed with sufficient frequency to maintain the utmost cleanli- 
ness and to relieve inflammation. Later on measures to promote 
absorption of inflammatory exudate and to prevent the formation 
of adhesions in the tympanic cavity become necessary. The 
internal administration of such remedies as the iodids in various 
forms, intranasal cleanliness, gargarisms, and occasionally a diapho- 
retic will be found to aid in this process. 

In uncomplicated cases the discharge gradually subsides and 
disappears altogether in from one or two days to four weeks. 

Careful hearing tests are made and recorded from time to time 
following an acute otitis media until the record shows practically 
perfect hearing, without tinnitus or evidences of adhesions. 
Recovery is never considered complete until the absence of exudate 
in the Eustachian tube has been clearly demonstrated by aural 
auscultation. 

During the later stages, after the intranasal infection has sub- 
sided sufficiently to permit it, beneficial results are occasionally 
obtained by catheterization, thus blowing the pus into the external 
auditory canal. 

In every case immediately after paracentesis a smear should 
be prepared for laboratory examination, always bearing in mind 
that a culture examination is preferable. Tuberculosis, diabetes, 
or syphilis as types represent conditions which seriously interfere 
with the general treatment of purulent otitis media, and the general 
examination of the patient at the first visit should elicit informa- 
tion on these points. In several instances the author has seen an 
apparently uncontrollable acute purulent otitis media rapidly sub- 
side as the result of proper dieting of a diabetic patient. 

After the acute symptoms have subsided, especially when the 
inflammatory exudate has been extensive, it becomes necessary to 



INFLAMMATION OF MIDDLE EAR. 209 

maintain the mobility of the drum and ossicles by means of various 
forms of massage. 

The complications are to be met as individual conditions. Pus 
retention must be relieved, furuncles incised; eczematous excoria- 
tions must be treated locally, periostitis "subjected to incision or 
relieved by local measures. Glandular swellings require the proper 
internal medication and application of soothing ointments — in other 
words, each complication as it arises must be treated as an indi- 
vidual lesion, and the treatment given must include the treatment 
of the otitis at the same time. 

OTITIS MEDIA NEONATORUM. 

This is a separate and distinct class of acute purulent otitis 
media occurring in the newborn child, the suppurative process being 
due to decomposing amniotic fluid in which bacteria find growth in 
the tympanic cavity. The disease is practically limited to its occur- 
rence in badly nourished and marasmic infants. While it presents 
the same etiological factors as purulent otitis media in adults, it 
has, in addition, to contend with the extreme susceptibility of the 
infantile mucosa to the influences of infection. The type of infec- 
tion is usually pneumococcus. The general symptoms of fever and 
emaciation frequently predominate over the local ear symptoms. 
In fact, extreme pain is rarely present. The temperature, however, 
is considerable. The exudate in the tympanic cavity, usually of a 
purulent character, shows no tendency to perforate the membrana 
tympani ; it should, therefore, be permitted to escape by perform- 
ing paracentesis even in the absence of violent ear symptoms, since 
the beneficial effects upon the digestion and general nutrition 
become most marked^ Whenever a newborn child presents the 
general symptoms of intestinal disturbance, catarrhal or pulmonary 
affections or malnutrition, the ear should be carefully examined, 
even in the absence of any symptoms pointing definitely to this 
organ. , 

The otitis media of the newborn infant is somewhat charac- 
teristic, and we therefore include it here as it is a type of acute 
purulent otitis media. 

Acute purulent otitis media in very young children may be 
complicated by the extension of the inflammatory agents from the 
tympanic cavity by way of the still open tympanomastoid fissure, 
resulting in mastoid abscess. The disease, while usually simple 
and amenable to treatment, commonly results in extensive necrotic 
mastoiditis, requiring operative interference. It may be stated, 
however, that usually otitis media neonatorum purulenta is a mild 
inflammatory process. 



CHAPTER XIX. 

DISEASES OF THE MIDDLE EAR. 

(Continued, | 

ACUTE DISEASES OF THE MASTOID PROCESS. 
Periostitis of the Mastoid Process. 

By periostitis is meant an inflammation of the periosteal cover- 
ing- of the mastoid process. It may he either primary or secondary. 
A periostitis localized to the posterior osseous canal wall, which 
is often observed, is in reality a subdivision of the secondary type 
of the disease. 

Primary Acute Periostitis of the Mastoid Process. 

Primary acute periostitis is a rare disease, and is more common 
in adults than in children. It is an inflammation which involves 
the periosteum of the mastoid process, and which varies in degree 
from that of a simple type to that of purulent periostitis. 

Symptoms. — The disease is characterized by a circumscribed 
inflamed area of periosteum of solid consistency, without involve- 
ment of the membrana tympani or external canal. As the disease 
progresses the soft tissues overlying the diseased area become 
rapidly tumefied and exhibit marked superficial redness. Y\ Ten 
located near the postauricular attachment the pinna is made to 
project unduly. Pain is severe and is accompanied by marked 
superficial tenderness upon pressure over the surface of the swell- 
ing. When severe, the affection induces considerable headache, 
slight fever and stiffness of the muscles upon the affected side. 

Primary periostitis often runs its course to resolution without 
suppuration ; occasionally an abscess formation results, but the 
disease rarely terminates in fistulous tracts and caries of the 
mastoid cortex. The latter complications occur only as a result 
of severe traumatism or some constitutional disease like syphilis 
or tuberculosis. 

Diagnosis. — It becomes necessary to eliminate primary disease 
of the mastoid cells, acute purulent otitis media, edematous derma- 
titis, glandular swellings and deep-seated furuncles in the posterior 
canal wall in order to establish a diagnosis of acute primary perios- 
titis of the mastoid. 

Prognosis. — The prognosis is favorable in uncomplicated cases. 

Secondary Periostitis of the Mastoid Process. 

Etiology. — In secondary periostitis the primary focus of inflam- 
mation is located either in the periosteum of the external auditory 
canal, with extension to that portion of the periosteum covering 
(210) 



DISEASES OF THE MASTOID PROCESS. 



211 



the mastoid, extension by contiguity from an acute or chronic sup- 
puration of the middle ear, or the mastoid cortex breaks down as a 
result of purulent mastoiditis. In nearly every case of furuncle 
involving the posterior wall of the external auditory canal there is 
more or less involvement of the periosteum covering the mastoid 
process. The author has observed many such cases accompanied 
by marked displacement of the pinna as a result of the tumefaction 




Fig. 124. — External periostitis of the mastoid process due to furun- 
culosis of the external auditory meatus and simulating advanced acute 
mastoiditis. 



and inflammation of the tissue. In both cases the external appear- 
ance seems to indicate advanced mastoiditis. One such case was 
referred by the family physician with a request that a mastoid 
operation be performed (Fig. 124). A free incision of a large 
furuncle within the canal in this case resulted in a cure, inasmuch 
as the mastoid cells were not diseased". Winn secondary periostitis 
is accompanied by acute or chronic purulent otitis, the periosteal 
involvement takes place by extension, from the tympanic cavity, or 
it results from the breaking down of the cortex, following involve- 
ment of the mastoid cells. 



212 THE MIDDLE EAR. 

Secondary periosteal suppuration resulting from purulent 
mastoiditis is more common in children than in adults, because the 
cortex is less dense and the anatomical sutures, being more or less 
open, permit pus from the deeper parts to reach the surface more 
easily than in the fully ossified sutures of the adult. 

Course. — Since secondary periostitis of the mastoid process 
invariably has a purulent origin it usually terminates in abscess. 
As a rule, the periosteal abscess either communicates directly or 
indirectly with a primary abscess located elsewhere. 

Secondary periostitis of the covering of the posterior bony 
external auditory canal wall may either follow acute or chronic 
purulent otitis media. In children, because the pus from the middle 
ear often finds vent externally through the petromastoid suture, it 
irritates and inflames the periosteum covering the bone in the 
auditor}- canal. Furthermore, the latter type of secondary periostitis 
may result from deep-seated furuncle or from injury. The later 
appearance of exostosis at the site of the periosteal inflammation is 
an unpleasant sequela. 

Diagnosis. — The diagnosis of secondary periostitis of the 
mastoid process must be determined by the presence of a post- 
auricular fluctuating swelling occurring in conjunction with the 
purulent mastoiditis, purulent otitis media, or furunculosis of the 
external auditory meatus. 

Treatment. — During the early stage of primary acute periosti- 
tis of the mastoid process the treatment is mainly antiphlogistic. 
The Leiter coil (Fig. 47) may be applied for from twenty-four to 
thirty-six hours. This relieves pain and retards inflammation. 
The coil is contraindicated whenever purulent exudate has already 
formed in the tissue. Dry heat, preferably the hot-water bottle, 
applied to the surface is soothing, and its employment is permis- 
sible, especially during the pus stage. Local depletion by blood- 
letting is also advised during the early stage.- Two or three drams 
of blood withdraAvn by means of an artificial leech (Fig. 58) 
applied near the border of the tumefaction will materially reduce 
the tension and afford relief. 

Whenever the inflammatory symptoms persist for three or 
more days and deep-seated fluctuation can be felt, the tumor should 
be incised freely in obedience to the laws governing all suppurative 
processes. Observing the usual rules as to asepsis, the incision 
should be of sufficient length to freely open the abscess cavity, 
extending through the periosteum to the bone. After evacuating 
the pus, all detritus or necrosed areas are to be removed by curet- 
tage, and the resulting cavity packed with sterile gauze. Since 
secondary periostitis arises from inflammatory or purulent disease 
of the auditory canal, tympanum or mastoid process, the essence 
of treatment lies in curing the provocative lesions. 



DISEASES OF THE MASTOID PROCESS. 213 



Acute Purulent Mastoiditis. 

The term mastoiditis is here employed to define an inflam- 
matory process involving- the tissues of the mastoid antrum and 
mastoid cells, which is induced by an invasion of pathogenic 
micro-organisms. 

With rare exceptions the disease originates in a similar process 
which has primarily developed in the tympanic cavity, the exten- 
sion being by contiguity through the aditus. 

General Pathology. — The contiguity of the mucous membrane 
in the mastoid process (lining of the mastoid cells) with the mucous 
membrane of the middle ear — tympanic cavity (Fig. 99) — having 
long since been definitely established by Bezold and Politzer, it 
follows that the mucosa of the mastoid antrum and mastoid cells 
usually becomes involved to some extent in every case of middle- 
ear suppuration. In the majority of cases, however, the purulent 
invasion of the mastoid process subsides very quickly in response 
to drainage and as a result of final resolution of the inflammation 
in the tympanic cavity. 1 According to Bezold, however, in at 
least 9 per cent, of cases of acute purulent otitis media, the inflam- 
matory invasion attacks some portion of the bone and tissues of the 
middle-ear tract, necrosis of varying degrees ensues, and thus a 
condition is produced which, strictly speaking, is pathologically 
designated as otitis rareficans simplex. 

The periosteal covering of the bony surfaces within the mastoid 
process, which is composed of the mucous membrane lining the 
cells, becomes swollen through hyperemia and infiltration with 
inflammatory exudate. The infiltration of the lining mucous mem- 
brane of the cells of the mastoid process interferes with the blood- 
supply of the intracellular bony walls. The tissue thus loses 
its fatty elements, and becomes converted into inflammatory granu- 
lation tissue. The blood-supply of portions of the osseous struc- 
tures having become lessened because of pressure on the vessels by 
the swollen tissues, bone necrosis ensues, and some absorption of 
the intercell-walls results. Thus from a series of small cells, 
lined with healthy mucous membrane, the mastoid process becomes, 
in a case of progressively advancing purulent mastoiditis, a bony 
process containing a series of larger cavities formed by the breaking 
down of the walls of the small cells, the inflammatory contents of 
which also coalesce. Eventually the progress of the disease reaches 
the outer (cortex) or inner (cranial) table, and, continuing, it may 
cause absorption at some given point. Absorption of the inner 
wall permits the infection to invade the middle or posterior cranial 
fossa, the lateral sinus or the labyrinth, depending upon the exact 
portion attacked. Absorption of the outer wall opens the cortex 
from within and the pus pours out directly underneath the perios- 
teum. In this event we have the condition designated as sub- 
periosteal mastoid abscess (Fig\ 125). Often, especially in children, 

1 Boenninghaus, Lehrbuch der Ohrenheilkunde, 1908. 



214 



THE MIDDLE EAR. 



the inflammatory invasion advances even farther by penetrating 
the periosteum, from which point it either escapes by directly per- 
forating the skin, or burrows downward into the cellular tissues of 
the neck. 

The determining factor in the entire pathological process is 
the purulent exudate, which seems to become caught in the network 
of cells in the mastoid process, and which, because of lack of out- 
flow, stagnates and spreads the infection. Boenninghaus claims to 
have proven that when, either through spontaneous perforation 
or surgical opening of the mastoid cortex, a flow of the retained 
pus is established, the further progress of the destruction of bone 




Fig. 125. — Subperiosteal mastoid abscess. 

ceases, thus demonstrating that the retention under pressure of the 
pus is the principal cause of the destruction of bone within the 
mastoid process. 

The pathologic lesions thus outlined have been grouped clinic- 
ally under the general term acute purulent mastoiditis. 

Etiology. — The same factors which enter into the causation 
of purulent otitis media may be considered as etiological to acute 
purulent mastoiditis. Strictly speaking, purulent mastoiditis is 
induced by an invasion of pathogenic micro-organisms into the 
mastoid antrum and cells from the tympanic cavity by the con- 
tiguous route, viz., the aditus ad antrum. 

Acute purulent mastoidal inflammation sometimes develops 
during the course of chronic purulent otitis media, and, while the 
apparently acute attack may only seem an exacerbation of the exist- 
ing chronic mastoiditis, the fact remains that, during the course of 
a chronic purulent otitis media, an acute purulent mastoiditis may 
occur at any time, so that chronic purulent otitis media must be 



DISEASES OF THE MASTOID PROCESS. 215 

considered as being in etiological relationship to acute purulent 
mastoiditis. 

Richardson and others have shown that the mastoid process 
may become involved in an osteomyelitis of the temporal bone. 
Occasionally a purulent process which has primarily involved the 
periosteum of the posterior external canal wall extends directly 
through its bony wall into the mastoid cells. This occurs in young 
children more often than in adults. 

Failure to establish timely and efficient drainage of pus 
through the drum membrane, either by spontaneous rupture or 
through incision in cases of acute purulent otitis media, is a 
common determining factor in the causation of acute mastoiditis. 
Infectious diseases, notably the exanthemata, influenza, typhoid 
fever and pneumonia, are provocative of middle-ear suppuration 
and mastoiditis, the invasion being partly due to the distinctive 
types of pathogenic organisms which characterize these diseases, 
and partly also to the greatly lowered vitality of the individual 
who has been subjected to prolonged suffering. 

Lowered vitality from any cause, whether from general sys- 
temic diseases, such as diabetes, Bright' s disease, anemia, constitu- 
tional vices or physical exhaustion, strongly predisposes to mas- 
toiditis, whenever a purulent otitis media ensues. 

The constitutional status undoubtedly plays a prominent role 
in the development of mastoiditis, whatever may be the exciting 
cause. Thus, syphilis and tuberculosis in the parentage or in the 
individual may be said to act as predisposing etiological factors, 
although the mastoiditis per se may not necessarily be either 
syphilitic or tuberculous in character. Among children this predis- 
posing dyscrasia, according to Korner and others, is of more than 
passing interest as an etiological factor in mastoid disease. The 
types mentioned in the preceding paragraph should not be con- 
founded with true tuberculous mastoiditis. 

Course and Symptoms. — Acute purulent mastoiditis is divisible 
into two general types : — 

1. A form which is almost painless but characterized by a very 
profuse otorrhea. 

2. A form evidencing intense deep-seated pain from the very 
beginning and having only a moderate amount of ear discharge. 

The first-mentioned type, wherein the attack of mastoiditis 
develops without pain and with a very profuse otorrhea, is the 
rarer of the two forms. Occurring in this form it is not easily 
recognizable, because of the absence of pain. There is but little 
pus retention and consequently little pain. The only fact that 
impresses the observer in this group of cases as significant is the 
excess of the ear discharge. Ordinarily, after an earl)- incision of 
the drum membrane for the relief of an attack of acute purulent 
otitis media, the ear discharge gradually subsides in from two to 
three days to as many weeks. As it subsides it gradually becomes 
less and less purulent, then mucopurulent and finally it gradually 
ceases. In such cases the cessation of the pus flow is coincident 



216 THE MIDDLE EAR. 

with the healing of the perforation in the drum membrane. But, in 
the cases of mastoiditis of the type under discussion, instead of this 
finding-, the character of the otorrhea becomes gradually more and 
more purulent as time goes on, even when the discharge was less 
marked at the commencement of the attack. The external auditory 
canal immediately refills with pus after being cleansed, and it is 
hardly possible to obtain an exact otoscopic picture. The momen- 
tary view reveals a red, infiltrated, and macerated drum membrane 
containing a perforation of varying size and location, through 
which there is a flow of pus which during the earlv stages may be 
streaked with blood. It is evident that this excessive flow cannot 
emanate from the tympanic cavity alone, and hence must come 
from the interior of the mastoid process. Especially pathog- 
nomonic, therefore, is the evidence furnished by a gradual increase 
in the quantity of purulent exudate. 

The general health necessarily must suffer under the bodily 
loss which is induced by the drainage of the excessive discharge. 
Hence_ the patient gradually becomes weak, the appetite suffers, 
there is loss of weight, and occasionallv there are elevations of 
temperature to be noted. During the latent stages the mastoid 
cortex may show no swelling and no tenderness to pressure, and 
subjectively the patients complain of no pain. The condition' may 
continue thus for a considerable period, although at any time 
pus retention may take place and cause pain and the other symp- 
toms typified in type two. 

In certain cases the mastoid cortex becomes perforated and 
then,_as the periosteum is reached, pain on pressure begins and 
swelling behind the ear becomes evident. In other cases, because 
of advancement of the lesion, the perforation takes place through 
the inner table of the mastoid and intracranial complications ensue. 
More^ rarely the labyrinth becomes involved. This tvpe of mastoi- 
ditis is, fortunately, not the most common, and it usually attacks 
those whose bodily resistance is lessened through intercurrent 
or preceding disease, especially young children and individuals of 
all ages who are affected with diabetes. 

The regular type of acute purulent mastoiditis, which is accom- 
panied from the beginning by pain and a more moderate otorrhea, 
is the most common type of the disease. Pain is evinced upon 
pressure and also felt subjectivelv by the patient. The initial point 
of tenderness from pressure is found over the mastoid antrum (Fig. 
127). (See diagnosis for details regarding points of tenderness oil 
pressure.) 

t The pain is due both to pressure from pent-up pus and to the 
inflammation of the intracellular mucosa. After perforation or 
incision of the drum membrane, the pain becomes less and remains 
less for a day or two as the otorrhea becomes established- then 
during succeeding days' it gradually becomes more intense, and 
meanwhile there is increased tenderness to pressure over the cortex 
of the mastoid. The latter symptom establishes a positive diag- 
nostic sis-n. 



DISEASES OF THE MASTOID PROCESS. ?17 

The pain of this type of mastoiditis, while rarely as excruciating 
as that which accompanies an attack of acute purulent otitis media 
previous to rupture of the drum membrane, is continuous, deep- 
seated and radiates over the entire side of the cranium. 

The facial expression is that of anxiety and suffering, and the 
patient usually inclines the head toward the affected side. 

A symptom of mastoiditis, which appears with comparative 
frequency and one which the author has never seen described in 
otological literature, is tension of the sternocleidomastoid muscle. 
This symptom is not invariably present. The tension is most 
marked when the tip cells are involved and when rupture of the 
mastoid cortex has taken place. 

In neglected cases, wherein the purulent process has not been 
relieved by timely operation, the fold (retroauricular) behind the 
concha gradually becomes obliterated, the ear, as the disease 
advances, stands off from the head (Fig. 125), the tenderness on 
pressure over the antrum and tip of the mastoid process and pos- 
teriorly over the entrance of the mastoid emissary vein increases, 
and, finally, if a subperiosteal abscess forms, fluctuation becomes 
evident. 

With the establishment of the subperiosteal abscess, the sub- 
jective pain usually ceases; but the swelling continues to extend 
over the region of the cortex, and unless relieved by operation the 
pus may reach the skin, which then becomes red and inflamed, and 
spontaneous perforation, especially in children, takes place. 

In a certain number of cases the pus from the interior of the 
mastoid process breaks through the incisura mastoidca behind the 
digastric muscle. This type of cases has been designated "Bczold's 
mastoiditis." It is more common in children, although Bezold esti- 
mates its occurrence in 20 per cent, of all cases. Hartmann (1888) 
describes another type wherein the pus penetrates outward through 
the zygomatic root and rupture takes place. 

The author has recently had under observation, at the New 
York Post-graduate Hospital, a case of this type. The patient, a 
child of about six years, had a fistulous opening into the zygoma, 
located about one inch anterior to the upper attachment of the 
auricle. The accompanying chronic purulent otitis media and a 
postauricular fistula, the result of an incomplete mastoid operation, 
furnished indisputable evidence that the zygomatic fistula was 
primarily the result of a purulent mastoiditis. 

In rare instances the pus burrows between the membranous 
canal wall and the posterior bony meatal wall. 

Finally, perforation ma}- take place through the inner cranial 
wall and cause an intracranial complication. 

The general health may remain undisturbed. Fever is present 
in about 50 per cent, of the cases, and in the majority of these only 
during the evening. In children temperature elevations are more 
frequent, and even convulsions are sometimes observed. 

In both types of mastoiditis we find drooping of the posterior 



218 



THE MIDDLE EAR. 



superior canal wall, thus narrowing the lumen of the canal (Fig. 
126). 

The drooping of the posterior superior canal wall, together with 
the bulging of the upper segment of the drumhead, the pain on pressure 
over the mastoid fossa (antrum), mastoid tip and mastoid emissary -rein, 
and the significance which must attach to excessive and continuous 
otopyorrhea which resists all approved measures of local treatment, 
constitute the classical symptoms of acute purulent mastoiditis. 

Diagnosis. — The so-called classical symptoms of acute mastoi- 
ditis mentioned in the preceding paragraph, viz., pain in the mastoid 
process, tenderness upon pressure upon the mastoid cortex 
(antrum, tip, zygoma, mastoid emissary vein) (Fig. 127), the 
quantity and character of the pus discharge, the bulging of the 





\ 














- y .•?;.*■ 



Eig. 126. — Lateral view of the external auditory canal and tympanic 
cavity, showing bulging of the posterosuperior canal wall into the lumen 
of the external auditory meatus. 



upper segment of the drum membrane and the drooping of the 
posterosuperior canal wall, when considered in conjunction with 
certain minor and less constant concomitant symptoms, to be here- 
inafter mentioned, are sufficient to determine the diagnosis. 

A differential blood-count (see Chapter VII) which records 
a marked increase in the leucocyte count and a high polynuclear 
percentage, when occurring in conjunction with other symptoms of 
the disease, tends to establish a diagnosis of purulent mastoiditis. 

Likewise the identification of the offending micro-organisms 
by a bacterial examination of the pus discharge, the methods and 
significance of which are described in Chapter V, aids in deter- 
mining the probable severity of the disease and. its diagnosis. 

Fever is not constant in adults, but is usually present in young 
children. There is no characteristic range of temperature in acute 
purulent mastoiditis, but when present fever is of diagnostic import. 

In a considerable proportion of the advanced cases an ex- 
amination of the mastoid process furnishes important material data 
regarding the diagnosis. The manner in which this is carried out 



DISEASES OF THE MASTOID PROCESS. 219 

deserves special mention. The patient should be seated with his 
back toward the light, and the examiner, standing directly behind 
him, should make a minute inspection of the exterior of the mastoid 
process and compare it with the mastoid process of the opposite 
side. 

Upon inspection, the first noteworthy fact developed in a case 
is the absence of the auriculomastoid skin fold. The external ear 




Fig. 127.— Showing the localizing points of tenderness upon pressure 
over the mastoid process. 

(concha) is often pushed outward and forward and lowered relatively 
to the concha of the opposite (healthy) side (Fig. 125). 

Upon pressure, tenderness is elicited at the fossa mastoidea 
(over the mastoid antrum) (Fig. 127). This is the most common 
localization of tenderness. Then, in the order of frequency of 
occurrence, pain is evinced by pressure upon the mastoid tip and 
along its posterior margin and over the seat of the zygoma (Fig. 127). 
Finally, pain is evident when pressure is applied at the site of the 
mastoid emissary vein, and upon its advent the mastoid operation 
should be performed. 

Radiography (Figs. 127a, b, c) furnishes valuable confirmatory 
evidence of purulent invasion of the mastoid process. 



220 THE MIDDLE EAR. 

Differential Diagnosis. — In rare instances there is pain and 
swelling over the region of the mastoid process as the result of 
edema due to a furunculosis of the external auditory canal (Fig. 
124). In this condition, in contradistinction to the swelling in 
acute mastoiditis, severe pain is evoked by any manipulation of the 
auricle, and the skin over the mastoid region can he pitted by 
pressure more than is possible in mastoiditis. The inspection of 
the external auditory canal finally, however, settles the diagnosis. 

Pain and swelling about the mastoid process may also occur 
as a result of inflammation of the mastoid lymph glands. This 
condition is generally the result of an eczema of the posterior folds 
of the concha or other neighboring parts. These glands are also 
often enlarged as a complication of chronic otorrhea. 

The diagnosis is easily made by means of the otoscopic picture. 
In acute mastoiditis it is extremely rare not to find the middle ear 
involved, while in the cases where the swelling is due to an 
inflammation of the lymphatics, the latter are usually localized and 
somewhat movable, and the examiner is often able to make out the 
outlines of the diseased glands. __ .. 

Whenever the external swelling is some distance back — that is, 
when it seems to lie over the mastoid emissary vein — it furnishes 
evidence of deep-seated and extensive disease of the mastoid proc- 
ess, and possibly of sinus-thrombosis or other intracranial compli- 
cations. Y\ nen the external swelling is low on the mastoid process, 
and has spread downward from the mastoid tip along the muscles 
of the neck, it is indicative of the type of mastoiditis heretofore 
designated as Bezold's mastoiditis. 

Preventive Treatment of Acute Purulent Mastoiditis. — The 
preventive treatment of acute purulent mastoiditis has already been 
clearly covered by the statement that patients at the very com- 
mencement of an attack of acute purulent otitis media (Chapter 
XVIII) should be placed in bed, given free purgation, and that free 
drainage of the tympanum should be established by means of a 
large incision through the drum membrane. 

In grippe cases or whenever the microscope reveals a strep- 
tococcic invasion of the mastoid process, no prolonged abortive 
attempts should be maintained. The same holds true in all cases of 
acute mastoiditis occurring in cases of chronic purulent otitis media. 
In fact, as soon as a positive diagnosis of pus invasion of the mastoid 
cells can be made, the time has arrived when operative interference 
must be seriously considered. The great increase in the number 
of mastoid operations performed in recent years has raised the 
question in many minds as to whether these operations are not 
performed with too great frequency. The question is proper and 
worthy of consideration. Intelligent conservatism should be the 
basis of action. 

There is but little doubt that the enthusiasm of some otologists 
has carried them beyond reasonable limits in operating upon cases 
of acute mastoiditis. Of the cases of acute purulent otitis media 
with tenderness over the mastoid antrum and even more general 



Fig. 127a. — The radiograph represents a normal mastoid process 
(pneumatic type). It will be noted that the zygomatic cells extend well 
forward. The numbered points in the radiograoh are interpreted as fol- 
lows : 1, the external canal through which the malleus is visible ; 2, the 
tip of the mastoid process; 3, the outlines of the auricle; 4, the outlines 
of the lateral sinus; 5, the condyle of the lower jaw. 





Fig. 12 



Figs. 127b and 2\7c. — The above cuts furnish a comparison between 
a healthy (left) mastoid process (b) and a diseased (right) mastoid proc- 
ess (c). It will be noted that on the normal side the outlines of the cell 
walls are easily distinguishable, while on the diseased side the lines are 
obliterated. The history was that of acute mastoiditis on the right side 
with the classical symptoms. Upon operating, the cells were thoroughly 
broken down, even in the zygomatic region. As a rule, the outlines of the 
lateral sinus (Fig. 252) arc defined in the radiograph. In tins case, how- 
ever, only the anterior sinus wall in the descending portion is visible. 
Successful radiographs of the mastoid process an- exccedinglv difficult to 
obtain and in every instance both mastoids should be taken., both for the 
purpose of comparison and for study of the anatomical relations. The 
latter are oftcner discernible upon the affected side. It should here be 
noted that, except in rare instances, the two mastoid processes are 
symmetrical. 



DISEASES OF THE MASTOID PROCESS. 221 

mastoid tenderness, when seen early, and plaeed in bed for observa- 
tion, drainage and local treatment, more than 50 per cent, recover 
without operation except incision of the drum membrane. 

On the other hand, in the private and hospital practice of 
expert otologists, a mistaken diagnosis is a rare exception. 

Even in the face of the large numbers of mastoid operations 
being performed today many patients are still deprived of their 
hearing and many lives are still sacrificed, as a result of either 
delayed operation or neglect to operate at all. Conservatism, so 
far as it relates to operation for acute mastoiditis, while always 
commendable and much to be desired, is, when carried to the 
extreme, detrimental to the interests of the patient. 

Treatment. — The treatment of acute mastoiditis in its early 
stages is exactly similar to that indicated for acute otitis media. 
The patient is put to bed, the membrana tympani freely incised, 
the patient's bowels and diet carefully regulated, and the affected 
ear is meanwhile douched with normal salt or warm bichlorid of 
mercury solution (1:2000 to 1:6000) every few hours. (For full 
details regarding douching of the ear the reader is referred to 
Chapter VIII.) 

The Bier method of treatment by artificially inducing hyper- 
emia has its advocates in' selected cases, notably Keppler and Heine 
in Europe and Kppetzky (Fig. 55) in America. This consists of 
placing a rubber band one-half inch in width about the neck, suffi- 
ciently tight to cause a hyperemia of the head. The hyperemia 
must be sufficient to render the skin warm to the touch, and the 
band must be kept in place eighteen hours in every twenty-four and 
must not be so tight as to impede the act of respiration or swallow- 
ing. As a remedial agent it seems to possess some abortive action 
upon acute mastoiditis when applied during the incipient stage, 
upon patients who are kept under close supervision. It must never 
be used in aged people, or those with arteriosclerosis, or those in 
whom there is kidney disease. In the later stages of acute mastoi- 
ditis the trial of the treatment has shown it to be valueless, and 
somewhat dangerous. 

In. fully developed purulent mastoiditis, or in a case where 
abortive measures have failed, the only treatment of value is of a 
surgical nature, and the operation indicated is the simple mastoid 
operation. Operation is indicated then, when the symptom-complex 
heretofore described is presented, or in cases developing more 
slowly and somewhat atypically, when the ear discharge has per- 
sisted' from two to four weeks (Korner), or to eight weeks 
(Bezold), and lias increased in quantity as the time passed rather 
than diminished. The operation is indicated when swelling, pain, 
or tenderness of the mastoid region persists longer than a week in 
spite of the instituted local treatment — applications of ice, etc. 
(Schwartze). 

Tn a recent paper 2 the author formulated his views as to the 



2 New York State Medical Journal, April, 1909. 



222 THE MIDDLE EAR. 

indications for the simple mastoid operation as follows: A simple 
mastoid operation is indicated wherever a purulent inflammatory 
process has invaded the mastoid antrum and mastoid cells with the 
following evidences : — 

1. Pain over the mastoid region. The pain is deep-seated 
and continuous, and radiates over the entire side of the cranium. 
The facial expression is that of anxiety and suffering. 

2. Tenderness on pressure over the mastoid cortex. The 
localizing points of tenderness are found over the mastoid antrum, 
the mastoid tip, along the zygoma and about the entrance of the 
mastoid emissary vein. Tenderness is sometimes entirely absent. 

3. Drooping of the posterosuperior canal wall, and bulging of 
the drum membrane which does not diminish as a result of 
paracentesis. 

4. Fever. The rise in temperature is not characteristic, but is 
more marked in infants and young children. 

5. Discharge. The discharge may be simply excessive with a 
tendency to increase rather than diminish; it may be of virulent 
type, or a sudden cessation of discharge may take place with 
simultaneous increase of mastoid pain. A prolonged profuse aural 
discharge which resists all approved measures of local treatment, 
including paracentesis, is considered by many otologists to furnish 
sufficient indication for the performance of the simple mastoid 
operation. Some recent experiences have led the author to believe 
that, given an acute purulent otitic inflammation with fetid odor, 
wherein it has been demonstrated that the invasion has been one 
of the more virulent types of pathogenic bacteria, and in patients 
of weakened vitality if the discharge manifests no tendency to 
abate after six or eight weeks, a mastoid operation must be seriously 
considered. In the majority of cases of this type occurring in my 
practice extensive disease of the mastoid cells has been found. 

6. Subperiosteal, postauricular swelling, with or without super- 
ficial abscess. 

7. The operation is imperative in the presence of symptoms 
of intracranial complications, or of purulent labyrinthitis. 

8. The advent of facial paralysis. This complication invariably 
indicates the necessity for an immediate mastoid operation, on 
account of the intimate relationship which exists between the facial 
canal and the labyrinth; 

9. Blood examinations (see Chapter VII) in conjunction with 
other symptoms of mastoiditis are of great diagnostic value. A 
high leucocytosis and polynuclear percentage indicates the presence 
of infection in some portion of the body. 

In addition to the above-mentioned indications, it may be 
stated that, on account of the manifest danger of serious complica- 
tions, the mastoid operation is a life-saving measure, and, although 
it is performed primarily in the interest of the life of the individual, 
there are secondary considerations which materially enhance its 
value, and, as a consequence, are worthy of note, at this point. 

The mastoid operation in acute mastoiditis quickly terminates 



DISEASES OF THE MASTOID PROCESS. 223 

a purulent necrotic process which otherwise might become chronic 
and attended with all the train of deleterious and dangerous results 
which accompany this troublesome affection. To mention them is 
sufficent: 1. Necrosis of bony areas which are closely related to 
vital structures. 2. The prolonged and constant danger of serious 
labyrinthine and intracranial complications. 3. Loss of hearing and 
persistence of otorrhea. 

It will thus be seen that, even though a patient suffering from 
acute mastoiditis might recover from the acute symptoms without 
loss of life, such recovery is prone to be followed by the sequela? 
above mentioned ;' whereas an operation, skillfully performed, in 
due season, brings to an end the purulent process, with perfect 
hearing results. 

The time for operative interference is ever dependent upon 
a satisfactory diagnosis of the presence of destructive purulent 
inflammation in the mastoid cells. Just when the exact time has 
arrived may not be measured by days or hours, but the simple 
mastoid operation should be performed in acute purulent inflam- 
mation which involves the mastoid cells, whenever a permanent 
remission of symptoms has not been effected either by drainage 
through the drum membrane, rest in bed, or the employment of 
the local measures heretofore described. 

Much has been written in favor of a so-called early, simple 
mastoid operation, and if by this is meant operation as soon as it 
can positively be demonstrated that a purulent inflammatory process 
has invaded the mastoid cells, which is too virulent and too exten- 
sive to offer any hope of spontaneous cure either by drainage or 
absorption, then the early operation is to be recommended. 

On the contrary, it is not wise to operate immediately upon 
every patient who has tenderness on pressure over the mastoid 
antrum, during the first three or four days of the attack, for the 
reason that in the milder cases it is quite possible for drainage 
through the aditus, combined with local absorption, to effect a 
cure without operation, and, further, it is deemed safer in the 
interest of the patient to operate after nature has thrown out some 
protective limitations to the disease within the mastoid cells. 

There are some dangerous indications which call for immediate 
operation, whatever the concomitant symptoms may be, and among 
these are : — 

(a) An acute mastoiditis occurring in an ear which is the seat 
of chronic purulent otorrhea. 

(b) Upon the advent of symptoms of labyrinthitis, the chief 
of which are destroyed audition, nausea, vertigo and nystagmus. 

(c) The appearance of facial paralysis. 

(</) The appearance of symptoms of intracranial involvement. 

To define the simple mastoid operation it may be stated that 
when properly performed it should extend to the limitations of the 
disease, and this usually calls for the removal of the mastoid cortex, 
the complete excavation of all mastoid cells, especially the large 
cells at the tip, those posterior to the sigmoid flexure, those about 



224 THE MIDDLE EAR. 

the roof of the zygoma; the curetment of all granulations and 
necrosed area--, and the establishment of postaural drainage of the 

mastoid cells and antrum. 

The simple mastoid operation, when skillfully performed and 
previous to the advent of serious complications, yields brilliant 
results, and is practically without danger to the life of the patient. 

The results may be summed up as follows: 1. Relief of pain 
and suffering. 2. Cure of a destructive purulent process, which 
otherwise menaces life and comfort. 3. Preservation of the function 
of hearing-, which otherwise might become destroyed on account of 
continued suppuration. It is the most invariable rule that the 
simple mastoid operation, when performed for the cure of acute 
purulent otitis media and mastoiditis, results in perfect hearing, 
and this is no mean argument in its favor. 4. It lessens the tend- 
ency to serious intracranial and labyrinthine complications, and 
the possibilities of recurrence are rare. 

In acute mastoiditis it is important to give careful attention to 
the patient's general condition, to the nature of the infection, and, 
so far as is possible, to the general conformity and character of the 
mastoid itself, making every effort to determine the extent to which 
the infection may have invaded the mastoid tissues. 

The nature of the infection, also, must receive due considera- 
tion. Various micro-organisms of the more virulent types have 
of late been carefully studied (see Chapter V). There is no specific 
germ of purulent otitis media; neither is its invasion invariably 
monomicrobic. In our present state of knowledge we must assume 
that the effects of the invading micro-organisms, so far as they 
relate to the various complications of purulent otitis media, are 
modified by the anatomical surroundings, the resisting power of 
the patient, and probably to some extent by the nature of the 
pabulum with which they are bathed. 



CHAPTER XX. 

DISEASES OF THE MIDDLE EAR. 
(Continued.) 

THE SIMPLE MASTOID OPERATION. 

Preparation of the Patient. — The preparation of the ear and 
area about it prior to the performance of the mastoid operation is 
of importance; hence, the process is herein described. 




Fig. 128. — Wooden block, grooved for head rest during operation upon 
mastoid process. (Devised by S. Richardson.) 

The patient should receive a general bath, including- a thorough 
flushing of the hair and scalp. This is followed by washing the 
scalp with a solution of bichlorid of mercury (1:5000). The hair 




Fig. 129. — The head in position upon grooved block. 



should be shaved from behind and above the ear for a distance of 
at least one inch from the hair line. The absence of hair on 
recovery is a source of considerable mortification to sensitive 
females, and no more should be sacrificed than is necessary in order 
to safeguard the wound during the healing process. It is not 
usually necessary to remove the portion immediately anterior to 
the auricle, and this serves to cover the denuded space when all 
dressings are over. 

15 (225) 



226 



THE MIDDLE EAR. 



The external auditory canal should be irrigated with a warm 
bichlorid of mercury solution 1:2000, wiped dry and then lightly 
packed with gauze. The area behind the ear should be thoroughly 
scrubbed with green soap and water, followed by ether, bichlorid 
of mercury solution 1 : 3000, and alcohol, care being taken to 
thoroughly cleanse the crease at the attachment of the auricle. 




Fig. 130. — Photograph showing the arrangements completed for 
performing a mastoid operation. 

A coating of collodion painted on the hair around the margin of 
the shaved area will prevent any stray hairs from getting on the 
operation field. 

In cases where from cosmetic or other reasons it is inexpedient 
to shave off any hair, it should be carefully combed toward the 
scalp in all directions from the mastoid area and thoroughly matted 
with collodion or a wide strip of adhesive plaster. A wet bichlorid 
of mercury compress is then bandaged over the mastoid process and 



THE SIMPLE MASTOID OPERATION. 227 

the ear, and the patient placed in bed to await the call to the operat- 
ing room. If time permits, an enema should be given before the 
operation. 

After the induction of anesthesia (for local anesthesia of the 
mastoid process see Chapter VIII and Figs. 50 and 180) and a sterile 
sheet and sterile towels have been adjusted about the shoulders, the 
nurse, after removing the compress from the mastoid, places a 
rubber bathing cap over the patient's head to prevent blood and solu- 
tions from getting into the hair. The operative field is again cleansed 




Fig. 131. — A complete set of instruments for the mastoid operation, includ- 
ing the emergency instruments required for complications. 

with ether and alcohol and three sterile towels are adjusted over the 
head, face, and neck in such a manner that the auricle and operative 
field only show through a triangular space left for that purpose. The 
exposed area should now be painted with tincture of iodine as a 
precaution against skin infection. 

The patient is now ready for the operator, who removes the 
tampon from the auditory canal. A wooden block (Fig. 128) or 
headrest placed underneath the head and neck serves to hold the 
former firmly in position (Fig. 129) and is much preferable to sand- 
bags, because the block does not easily become displaced. The surgeon 
should have the aid of one experienced assistant and two nurses, in 
addition to the anesthetist (Fig. 130). 

Instruments. — A complete set of instruments, carefully steri- 
lized by boiling, should be at the command of the surgeon, for, 



228 



THE MIDDLE EAR. 



while only a few may be required, every emergency should be pro- 
vided for. In order to meet the requirements a rather extensive 
armamentarium will be found necessary. The accompanying cut 
I Fig. 131) illustrates those which the author's experience has found 
sufficient to meet all requirements. 

It is of extreme importance that the operative field be fully 
illuminated. Artificial light is usually necessary, although occa- 
sionally operating rooms are so arranged that sufficient direct light 
is obtainable. Artificial light, when required, is usually obtainable 
through the employment of the ordinary hand electric light, or, 




ZYGOMA 



LJNEA 

TEMPORALIS 



MASTOID 

FOSSA 
SPINE OF 

HENLE 

SUPRA-MEATAL 
SPINE 

SQUAMO- 

"enJP.iPpJ-^' 4 H KM>l'M^ ^— GLASERIAN 

FISSURE 

TYMPANIC PLATE! 

EXTERNAL / \^V4/ ^k^-CiTYLOin PROCI 

AUDITORY CANAL ^T 

MASTOID 

PROCESS 

Fig. 132. — Temporal bone, external surface, showing landmarks. 



preferably, an electric headlight. The author's headlight (Figs. 5 
and 130), which is portable and can be used with a dry-cell battery, 
or attached directly to the street current by the interposition of a 
suitable controller, has been found exceedingly serviceable in this 
connection. By its use a strong, steady bright light is thrown 
directly into the operative field. 

It is especially efficacious in illuminating the deeper portions 
of the operative field. 

Surgical Anatomy. — The exposed bone (Fig. 140) after re- 
traction of the soft parts shows a field limited in front by the 
posterior wall of the external auditory canal, and an irregular line 
downward to the mastoid tip. Above and extending backward from 
the root of the zygomatic process is seen the linea temporalis (Fig. 
132). This line serves as a guide, above which it is unsafe to go, as 
it marks in a general way the level of the middle cranial fossa. 
From the mastoid tip, extending upward, there is often seen, in the 



THE SIMPLE MASTOID OPERATION. 



229 



very young and in childhood, the squamomastoid suture or its 
remains, which in the adult is only marked by a fine shred of 
adherent periosteum. 




Fig. 133. — The primary incision through the soft tissues of 
the mastoid process. 

Behind the upper posterior angle of the external auditory canal 
we see the spine of Henle, and immediately behind Henle's spine 
the spongy spot, usually a depression known as the supramastoid 
fossa, is located (Fig. 132). This supramastoid fossa, with the 




Fig. 135. — The Douglas periosteal elevator. 



spine of Henle, together with the curved outline of the bony 
meatus, form important guides in approaching the mastoid antrum 
while operating upon the mastoid process. 

There are several methods for locating the mastoid antrum. 
It is usually located by using the suprameatal triangle as a guide 
(Fig. 132). This triangle is an imaginary triangle bounded above 



230 



THE MIDDLE EAR. 



by the continuation backward of the zygomatic root or the linea 
temporalis, in front by a line coincident with the direction of the 
posterior bony canal wall, and behind by an imaginary line con- 
necting the other two lines. 

This triangle has been used for a long time as the safest guide 
to the antrum, but the author has discarded this guide in favor of 
the depression or fossa which lies immediately posterior to the 
spine of Henle, for the reason that the small fossa above mentioned 
is a safer and more positive guide to the mastoid antrum. When 




Fit 



136. — Cutting the outer portion of the attachment of the sterno- 
mastoid muscle to the tip of the mastoid process. 



the suprameatal triangle is followed it cannot be safely entered at 
all points of its area, inasmuch as occasionally the course of the 
lateral sinus is so far forward as to encroach upon this space. 
When the suprameatal triangle is used as a guide the operator should 
in all cases bear in mind the importance of keeping as close to the 
osseous meatus as possible. While Henle's spine is not invariably 
present, the depression is always to be found, and generally a slight 
elevation at least marks the position of the spine. With these 
landmarks to guide him the surgeon may gradually chisel directly 
inward, forward and upward through the bone, without fear, to a 
distance equal to the depth of the external auditory canal, when the 
antrum will be found to have been entered (Fig. 143). The avail- 
able space is often limited to a small area on account of anomalies 



THE SIMPLE MASTOID OPERATION. * 231 

.in the course of the lateral sinus, or because the dura lies unusually 
low. 

The Operation. — The primary incision should be made in a 
manner which will facilitate and simplify the subsequent steps of 




Fig. 137. — Allport's mastoid wound retractor. 

the operation. The lower portion of the mastoid should be care- 
fully palpated and the incision commenced as nearly as possible to 
the centre of the tip near its lowest border. The point of a medium- 




Fig. 138. — Jansen's mastoid wound retractor. 

sized scalpel is then plunged through the soft tissues, including the 
periosteum, to the bone and the incision extended directly upward 
for a short distance, or until the blade has reached the upper point 




of attachment of the sternocleidomastoid muscle. From this point 
the incision is extended forward toward the auricular attachment 
and is completed upward in curvilinear form, following the curve of 
the auriculomastoid attachment to a point even with or above the 
higher point of said attachment. The curvilinear portion of the 



232 



THE MIDDLE EAR 



incision should be about }% inch posterior to the auriculomastoid 
skin fold (Fig. 133). 

In order to control the line of incision the pinna is folded for- 
ward and hekl firmly against the head, without being pulled away 
from its normal location (Fig. 133). Assistants are prone to pull 
the ear forward, in which event the incision may enter the external 
auditory canal instead of being posterior to it. 

By commencing the incision at the middle of the mastoid tip, 




Fig. 140. — Showing the cortex of the mastoid process with the soft tissues 
retracted by self-retaining retractors. 

the operator is afterward enabled with one or two clips of a curved 
scissors to quickly sever the outer portion of the mastoid attach- 
ment of the sternomastoid muscle (Fig. 136), and thus denude the 
tip area of its covering. Whenever the primary incision is made 
at too great a distance from the attachment of the auricle, it 
becomes difficult to retract the anterior portion of the wound suffi- 
ciently to reveal the necessary surgical landmarks, especially the 
spine of Henle and the posterior border of the bony meatus; and, 
furthermore, the remaining scar being further from the auricular 
attachment is more unsightly. Hence the ideal incision should lie 
comparatively close to the auricle, where the scar almost becomes 
lost in the auricular mastoid skin fold. 



THE SIMPLE MASTOID OPERATION. 



233 



The incision having been completed and the hemorrhage from 
all severed blood-vessels controlled with artery clamps, the perios- 
teum over the entire area of the mastoid process is rapidly retracted 
by means of periosteal elevators, and thus the entire cortex is 
exposed to view. The Langenbeck or Hoe elevator is well- adapted 



& ,-, f~-.}}^r'^y' \ 




Fig. 141.-^The posterior mastoid incision. 

for retracting the posterior periosteal covering, and for the main 
portion of the periosteum which lies anterior to the incision (Fig. 
134). The Douglas periosteal elevator (Fig. 135) is serviceable in 
the areas where gentler manipulation is imperative, especially when 
forcing the periosteum from the borders of the bony external 
meatus. 



234 



THE MIDDLE EAR, 



In order to completely denude the outer surface of the mastoid 
tip, the fibres of attachment of the sternomastoid muscle must be 
severed over this area 1>\ means of a strong curved scissors, or knife 
(Fig. 136). The anterior flap, together with the periosteum, is 
then pushed well forward until the bony outline of the posterior 
border of the external auditory canal has come well into view, care 
being exercised, however, not to penetrate the membranous canal 
or tear it from its attachments. One or two self-retaining- retract- 
ors. Allport's (Fig. 137), Jansen's (Fig-. 138), or Jack's (Fig. 139), 
are then introduced and the soft tissues, including the periosteum, 
widely opened, thus exposing the entire area (Fig. 140). This 
unfolds to the operator the landmarks necessary to open the way 




the antrum cortex. 



to the mastoid antrum. These preliminary procedures are the 
keynote to the proper performance of the mastoid operation, and 
he who fails to bring to his view the posterosuperior border of the 
canal, the spine of Ilenle and the supramastoid fossa before attempt- 
ing to enter the antrum, fails there!)}' in establishing control of the 
situation. 

Whiting and others advise a posterior incision to extend back- 
ward at right angles to the first incision in all cases. The posterior 
incision is necessary and desirable in large pneumatic mastoids in 
which the disease has encroached upon the posterior cells, and in 
cases of lateral sinus-thrombosis or cerebellar abscess. Otherwise 
it is an unnecessary procedure. Besides being unnecessary in all 
cases, the posterior incision adds to the unsightliness of the scar. 
It is rarely called for in children and in less than 50 per cent, of 
adults. The line of the posterior incision should extend from the 
spine of TTenle directly backward toward the occipital protuberance 
(Fig. 141) to the required distance. This selection is obviously 
made in order to follow the course of the lateral sinus. 



THE SIMPLE MASTOID OPERATION. 



235 



It is never necessary or expedient to make a posterior incision 
until the operation has progressed to a point where it can be deter- 
mined that complete excavation cannot well be accomplished 
without it. In many cases extensive disease becomes apparent upon 
removing the major portion of the cortex, hence the posterior 
incision becomes necessary at the beginning of the operation. The 
cortex is now exposed and the next step in the procedure is the 
opening of the mastoid antrum. The antrum is entered either by 
using the mallet and chisel or gouge, which are the generally 
accepted instruments for the work. American otologists have 
generally discarded the trephine for opening the mastoid cortex, 
and the hand gouge for this procedure has but few advocates. 




Fig. 143. — The mastoid antrum opened and a curved probe inserted 
through the aditus. 

Selecting a chisel with a blade about Y§ inch in width (Fig. 
142), which is held firmly by the surgeon with some portion of the 
hand resting upon the patient's skull to insure support, control and 
accuracy, by cutting first in an upward and then in a downward 
direction with the chisel, a few strokes will usually chip off the 
bone and the blade will pass through the cortex. During this pro- 
cedure great care should be exercised to prevent the chipping away 
of the osseous canal wall. In some individuals the cortex is 
extremely thick and in others it is either thin in conformation or 
has been undermined by the underlying purulent process. 

In pneumatic mastoids with softening, or when pus is present 
throughout these structures, the chisel may be discarded as soon as 
the cortex has been cut through, and the operation completed with 
the curet and rongeur forceps (Fig. 1-16). The curet is to be 
preferred to the chisel, the reasons for which are outlined in suc- 
ceeding paragraphs, providing the tissues are sufficiently soft to 
yield to its sharp cutting edges. It is of the utmost importance 



236 



THE MIDDLE EAR. 



that chisels be of the finest steel and always kept sharp (Fig. 144). 
Both chisels and curets should be held with great firmness and 
always with control, in order to prevent serious accidents, the chief 
of which are wounding the lateral sinus and meninges and injury 
to the facial nerve. In young children the osseous tissues are 




Eig. 144 — Set of mastoid chisels and gouges. 



extremely soft and a blow upon a chisel which is not sufficiently 
controlled by the operator may drive it through both tables of the 
skull with serious consequences. 

After entering the mastoid antrum a curved silver probe or 
Bowman's eye probe sharply curved at the tip may be introduced 
into the opening and pushed gently forward into the aditus ad 
antrum (Fig. 143). If the probe "freely enters in the manner 



THE SIMPLE MASTOID OPERATION. 



237 



described one is assured that the antrum has been entered. To 
operators of wide experience this procedure is rarely necessary. In 
infants and young children the mastoid antrum lies nearer the 
surface of the cortex than in adults (Fig. 62). 

The antrum is usually found situated just posterior to and 
above the external auditory canal. That is, taking the posterior 
canal wall as a guide, it will be found located just behind it and at a 
few lines elevation above the upper pole of the canal. 

This corresponds to the mastoid fossa, located in McEwen's 
triangle. 

A practical guide is to assume the canal walls to be the rim 
of a clock dial, and at a place representing between one and two 




Fig. 145. — Removing the cortex with rongeur forceps. 



o'clock, or eleven and twelve o'clock, depending upon when the 
side is right or left, a line continued a few millimeters beyond the 
dial rim will indicate the cortex over the antrum. 

Its depth is, generally speaking, a few millimeters beyond the 
depth of the external auditory canal. The quotation of figures is 
of little use, inasmuch as the distance varies in different individuals, 
being relative in depth to the depth of the external auditory canal. 

The size of the antrum varies according to whether the given 
mastoid is pneumatic or not, being smallest where eburnation is 
marked. 

After entrance to the antrum has been definitely accomplished, 
and a portion of the surrounding wall of cortex has been cut away, 
a careful search is instituted by probes or curets in order to locate 
the route which the infection lias followed. As a rule the probe 
indicates a track leading toward the mastoid tip, or one leading 
backward over the knee of the sinus. Occasionally it leads upward 
and forward into the region of the zvsromatic cells. It is well at 



238 



THE MIDDLE EAR. 



this point, providing the original opening permits, to do a moderate 
amount of excavating with a sharp spoon curet, and then with a 
few bites of strong rongeur forceps to cut away that portion of 
the cortex which overhangs the excavation. Then by introducing 
the forceps after the manner depicted in the illustration (Fig. 145) 
a furrow of cortex is removed downward to the" mastoid tip. 

The indiscriminate use of the mallet and chisel in the mastoid 
operation is to be condemned on account of the shock produced by 
the blow of the mallet. It is far more desirable to rely upon the 
curet or the various forms < f rongeur forceps (Fig. 14')) for 
removing the cortex, together with the underlying diseased tissues, 




Eig. 146. — Excavating cells and granulations with curet, and the technique 
of biting the overhanging cortex with the rongeur forceps. 

because the blow of the mallet upon the chisel, directed always 
with more or less force toward the patient's brain, produces a 
certain degree of nervous shock, and, even though the patient is 
under anesthesia, the effect of the blow upon the brain is more or 
less harmful. 

In this connection it is interesting to note the result of observa- 
tions made by Grossman, of Berlin, who took sphygmographic trac- 
ings of the pulse and blood-pressure during numerous mastoid 
operations, in an effort to estimate the effect of the chisel and 
hammer blows. Mis observations demonstrated that the use of the 
chisel was a severe shock to the entire system, as evidenced by the 
rapid and irregular pulse beats during the act of chiseling. 

The disagreeable effects of mallei ing may be demonstrated by 
a blow with a mallet upon a blunt piece of iron placed against any 
portion of <>nc'-> own skull. Where possibly a cerebral abscess, 
meningitis, or a thrombosed' lateral sinus is present, serious acci- 
dents might occur as a result of the vibrations of the blow from the 
mallet, and its use should, therefore, be limited as much as possible. 



THE SIMPLE MASTOID OPERATION. 



239 



It may be further argued that the rongeur forceps are a much 
more rapid and precise method for removal of the cortex and 
diseased bone. 

When pus and granulations are encountered in the areas adja- 
cent to the mastoid antrum, it should be the invariable rule to 
extend the excavations downward to the mastoid tip, using heavy 









. ■'.- • \ 












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m^a& ■&"'''- 


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' 














r 'fir jfj 


i," • 




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. 







Fig. 147. — The specimen shows a continuation of the mastoid cells 
into the basilar process of the occipital bone. (From Dr. Wm. M. Dun- 
ning's collection.) 



curved rongeur forceps for removing the cortex, and following 
with a sharp, strong curet until all the tip cells are removed and a 
smooth surface remains. This procedure often necessitates the 
exposure of portions of the digastric muscle. The cells of the 
mastoid process are occasionally contiguous with the diploic struc- 
tures of adjacent bones (Fig. 147). 

Various strong, well-made rongeur forceps, nf different sizes 



240 



THE MIDDLE EAR. 



and shapes, are necessary in order to skillfully and rapidly accom- 
plish the desired results (Fig. 148). 

A mastoid operation usually demands the removal of practi- 
cally the entire cortex, together with the underlying pneumatic 
.structures, and all the diseased hone found, until at last nothing 
but a health}-, firm bony area remains. Then all rough edges and 
projections are to he scraped away, leaving a smooth surface (Fig. 
14''). The excavation is irregular in contour, extending from 
the legmen above to and through the mastoid tip below and from 




Fig. 14S 



common use. 



the posterior border of the osseous canal wall backward, usually to 
the limit of the pneumatic cells. Only the antral orifice of the aditus 
should be curetted for fear of dislocating the incus. 

Tt is difficult to positively differentiate between healthy and 
infected pneumatic cellular tissue; indeed, it is doubtful if all the 
diseased tissue is ever completely removed. The resulting wide- 
open space, no longer hampered by overlying diseased bone, gradu- 
ally becomes covered with healthy granulations and assumes a 
normal, healthy state in response to nature's efforts to eradicate 
the disease. 

It is quite common to find that portions of the inner table have 
broken down from extension of the disease, thus necessitating the 
exposure of the lateral sinus or the dura covering the middle cranial 
fossa (Fig. 150). The cells of the zygoma, being contiguous to 



THE SIMPLE MASTOID OPERATION. 



241 



those of the antrum and attic, are more extensive than is supposed, 
and are often involved, both in adults and children. 



:...;.; ' 



mi 



Fie-. US 



d simple mastoid operation. 




Fig. 150. — Showing ('1 ) exposure of the dura in the region of the antrum 

and attic tegment, and (2) exposure of the lateral sinus. 



No mastoid operation is complete without a careful inspection 
of the cells of the root of the zygoma and the removal of all patho- 
logic tissues found therein (Fig. 151). In broad pneumatic mas- 
toids a comparatively enormous area of cortex is necessarily 
removed during the mastoid operation, the excavation often extend- 

1G 



242 



THE MIDDLE EAR. 



ing far forward into the zygoma and posteriorly into the occipital 
bone. 

In an otherwise healthy individual the subject of an infection 
of the mastoid process following an acute purulent otitis media, 
the .simple mastoid operation meets all the surgical requirements, 
providing it is not unduly delayed. 

THE MASTOID OPERATION ON INFANTS AND 
YOUNG CHILDREN. 

As has already been shown in Fig. 62. there is absence of the 
osseous meatus and mastoid cells at birth ; therefore, the mastoid 




Fig. 151. — Extensive excavation of the mastoid process and the zygo- 
matic cells, and, posteriorly, the diploe of the occipital bone. (From Dr. 
Win. M. Dunning's collection.) 

antrum and the tympanic cavity are nearer to the surface of the 
skull. Consequently the landmarks which serve as a guide to the 
mastoid antrum in the adult are somewhat different in the child. 
Here the lower border of the root of the zygoma may be used as a 
guide to the upper level of the mastoid antrum. In conformity with 
the undeveloped mastoid at this age, the emergence of the facial 
nerve from the skull and its course downward is extremely super- 
ficial, which necessitates considerable care in making the primary 
incision for the mastoid operation. In all cases the site of the 
incision should be at least one-fourth of an inch posterior to the 
auricular attachment. It is important that the pressure upon the 
knife during the incision should be under perfect control in order 
to prevent possible injury to the deeper structures, which are some- 
times extremely soft. Fortunately, in a large proportion of the 



THE SIMPLE MASTOID OPERATION. 



243 



cases of acute mastoiditis in infants there is perforation of the 
external table, from which point the excavating is easily conducted 
by means of a curet or small rongeur forceps. As a rule the 
small "spongy spot," which in the adult occupies the space imme- 
diately posterior to the spine of Henle, is visible. 

While there are few or no mastoid cells in very young chil- 
dren, the diseased space usually covers a considerable area, both in 
depth and width. In infants the mastoid antrum should not be 



\J 




Fig. 152. — Author's portable operating table. A, In position, showing 
angles and extension of headrest and footrest. B, Folded for inserting 
into case. Weight, 29 pounds. 



curetted on account of the possible separation and removal of the 
incus. 

The Operative Findings During Simple Mastoidectomy. — In 
typical cases of acute mastoiditis, upon opening the cortex over the 
mastoid antrum, pus will exude, and sometimes under pressure. If 
the operation is performed at a very early stage, the interior 
of the mastoid process will appear intensely engorged and hemor- 
rhage will be profuse. 



244 



THE MIDDLE EAR. 



At this stage the disease may not extend far beyond the con- 
fines of the antrum. As a rule the freer the drainage through the 
external auditory canal, the less will be the quantity of pus in the 
mastoid cells. There are exceptions to this rule in cases where 
operation has been delayed until the walls of the cells have broken 
down and coalesced into large cavities, which are then found filled 
with pus and granulation tissue. When the pus wells up in large 
quantities, flows copiously and pulsation is observed, strong indica- 




Fig. 153. — Author's complete sterilized outfit, covering all. neces- 
sary paraphernalia for the mastoid operation, except instruments. 
Rubber cap, half sheet, two dozen towels, three gowns, two cotton 
caps, gauze wipes, absorbent cotton, plain gauze packing, iodoform 
packing, bandages, green soap, bichlorid tablets, adrenalin, alcohol, 
ether, collodion, two nailbrushes, pus basin. 



tion is thereby given that the internal table has broken down, with 
exposure of the lateral sinus or meninges. 

Whiting has emphasized this symptom. So long as the puru- 
lent process is confined to the bony structures of the interior of 
the mastoid process, even though the inner table has broken down, 
thereby exposing the lateral sinus or meninges, there is but slight 
danger of further extension to these structures, provided they have 
resisted infection up to this time and are further freed from all 
overlying infected bone. Tf the exposed surfaces of the meninges 
or lateral sinus are covered with healthy granulations, these should 



THE SIMPLE MASTO.ID OPERATION. 



245 



never be scraped away, as they furnish abundant indication that 
nature has already thrown out a safety barrier against the further 
progress of the disease. 

The completed surgery of the bone usually reveals the dense 
surface of the external semicircular canal (Fig. 149). The facial 
nerve (Fig. 240), which normally lies well within the inner table, is 
rarely encountered except when the disease has attacked this 
portion of the bony structure of the mastoid. 

In removing diseased bone which lies directly over the digastric 




Fig. 154. — Portable sterilizer. Alcohol burner. 



muscle considerable care is necessary to avoid injuring the facial 
nerve at this point. 

Cholesteatomata are found in cases of acute mastoiditis only 
when the acute mastoiditis occurs in conjunction with chronic 
purulent otitis media. 

It is sometimes inexpedient to remove a patient suffering from 
mastoiditis to a hospital or sanatorium for operation. Under these 
circumstances it often becomes necessary to improvise an operating 
table from one or two small tables, which may be protected with 
sterile sheets. In order to meet emergencies of litis kind the 
author has devised 'a portable operating table (Fig. 152), which 
may be folded and placed in a suitable case and transferred in an 
ordinary cab. He also keeps on hand, and ready for any emer- 
gency, a sterile outfit of all the necessary materials required during 
the mastoid operation. They are enumerated in Fig. 153. In 
addition a small portable sterilizer which can he heated by an 



246 



THE MIDDLE EAR. 



alcohol burner (Fig. 154) is requisite when operating at a patient's 
home or in a hotel. 

Upon the completion of the operation all bleeding vessels 
should be twisted or tied, and the wound in the soft tissues made 
smooth by the removal of loose fibres of muscle or periosteum. 
The entire wound should then be irrigated with hot normal salt 
solution. Many operators precede the irrigation by filling the 
wound with peroxid of hydrogen. After irrigation the entire 
cavity is wiped dry with sterile gauze and lightly packed with 




Dig. 155. — The mastoid wound packed with gauj 
portion united with sutures. 



1-inch sterile iodoform gauze, up to the borders of the external 
wound (Fig. 155). In packing it is important that any exposed 
areas of dura or lateral sinus be covered with small sections of the 
gauze before packing the remainder of the wound cavity. 

It is advisable, especially when the primary incision has been 
extensive, to partially suture it, particularly in its upper portion 
( Fig. 155). When a posterior incision lias been necessary, it should 
be completely sutured at the completion of the operation. 

In suturing it is imperative to leave sufficient room for the 
subsequent removal and insertion of the necessary dressings. The 
dressing is completed by applying gauze wipes, which are shaped 
in a manner to protect both the ear and the wound. Usually one 
piece is shaped to lit the space posterior to the concha; another is 



THE SIMPLE MASTOID OPERATION. 



247 



placed in front of the ear, and two or three more are applied over 
the entire area and the bandage is then applied. 

In the first step of applying the mastoid bandage the outside 
dressings are anchored into position (Fig. 156). Having secured 
the dressings, the bandaging is carried out somewhat by the figure- 
of-eight method until the dressings are completely covered, leaving 
a smooth outer surface which does not become detached (Fig. 



157). This method of bandaging- the mastoid originated 
Manhattan Eye and Ear Hospital. 



the 




Fig. 156. — First step in applying the mastoid bandage. 

In the event of the performance of a double mastoid operation, 
the bandage is applied over both ears in a manner somewhat similar 
to that described above for the single operation (Fig. 158)/ 

The Blood-clot Method of After-treatment. — Blake and others 
have advocated the use of the blood-clot method of closing the mas- 
toid wound. This consists in allowing the bone cavity of the wound 
to become filled with fresh blood which has oozed from the exposed 
blood-vessels therein. The external wound is then completely closed 
by means of a silver-wire suture subcutaneously applied. The wound 
is then covered by several sheets of sterile silver foil with a top dress- 
ing of several layers of dry sterile gauze, hoping thereby to obtain 
union by primary intention, and to secure an organized blood-clot 



248 THE MIDDLE EAR. 

within which will not break down or suppurate. Unfortunately the 

results of this method of closing the mastoid wound have not seemed 
to warrant its general employment. When successful, the wound 
should he completely healed and the middle ear dry and free from 
pus in from seven to fourteen days. 

The indications that a retained clot is disintegrated are fever, 
the appearance of excessive aural discharge, foul odor and oozing 
of pus between the stitches in the external wound. The advent of 
these symptoms renders it necessary to open up the external wound, 




Fig. 157. — The completed mastoid bandage. 

to cleanse its interior, and to complete the treatment of the case 
by the open method. By closing the postauricular wound with 
Michel's clamp sutures (Fig. 213), the possible danger of con- 
taminating the wound from stitches is eliminated. 

After-treatment of the Mastoid Wound. — The patient having 
been returned to his bed is given the usual postoperative treatment 
in order to combat the effects of shock and aid in the recovery from 
the anesthetic. A warm bed, hot-water bags to the extremities, 
and small doses of hot water to relieve nausea are all useful. AVhen 
the loss of blood is considerable or shock is evident, or in patients 
who have been weakened by prolonged infection or some general 
disease, great benefit is obtained from large high enemas of hot 
normal salt solution. 



THE SIMPLE MASTOID OPERATION. 



249 



The mastoid wound requires skillful care if the final outcome 
of the case is to be safeguarded. The mastoid wound demands 
repeated dressings. The first dressing - is permitted to remain in 
place, in the absence of complications, for four or five days ; there- 
after it is changed every second day or daily as the case may 
demand, the object being to have the wound fill in from the bottom 
with healthy granulations before closure at the periphery. 

Excessive granulations are clipped with scissors or checked by 
applications of silver nitrate ; indolent granulations stimulated by 
the application of balsam of Peru and castor oil in equal parts, or 




Fig. 153. — The double mastoid bandage. 



by packing with iodoform gauze, or by massage, the latter by 
means of rubbing with a cotton-tipped probe. 

The middle ear is inspected at each dressing, the external canal 
cleansed, and a gauze drain inserted in the external auditory canal; 
As the granulations advance, care is exercised to prevent the skin 
edges of the outside wound from turning inward, and thus the 
possibilities of a depressed scar as an end result are avoided. In 
favorable cases the patient may be allowed to sit up in bed on the 
third day, to dress and move about the room on the fifth day, and to 
leave the house or hospital in from a week to ten days. 

The first wound packing is of iodoform gauze. Subsequent 
dressings unless otherwise indicated demand only plain gauze, 
lightly packed into the wound cavity. The general surgical prin- 
ciple, that a healing wound should be left at rest, must be heeded, 
and, when everything is progressing favorably, the less the wound 
and granulations are manipulated, the better. 



250 



THE MIDDLE EAR. 



Peroxid of hydrogen is the usual cleansing agent applied to 
the healthy granulating surface. In the final healing, which is 
usually completed in from six to eight weeks, there is considerable 
bone regeneration and usually no unsightly deformity. 

Postoperative Temperature. — Following the simple mastoid 
operation for mastoiditis there is usually a sharp rise of tempera- 
ture. Harris, who made a study of 103 cases of postmastoidal tem- 
perature, has shown that this rise is due to absorption from the 



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Fig. 159. — Postoperative temperature curv 
flat temperature. 



showing continuous 



wound surfaces. The temperature gradually rises as high as it was 
before operation, but rarely higher. It persists for some days, 
usually dropping toward the end of the second day after operation. 
In rare cases it may persist for some days longer. This rise of 
temperature is usually without significance, but its persistence 
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intracranial complications. Figs. 159, 160 and 161 are appended in 
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Fig. I'd. — Temperature chart, showing the usual postoperative rise in 
temperature on the day following the operation, with a gradual decline 
until the fifth day and a sharp rise to 103.4° on the fifth day, the result 
of an attack of mastoiditis in the opposite ear. C51) 



252 THE MIDDLE EAR. 

perature curve in Fig. 161 is a more rare occurrence in which a 
secondary elevation is caused by infection elsewhere, or by some 
complication. In this case mastoiditis developed in the opposite 
ear coincident with the second rise of temperature. 

Complications of the Mastoid Wound. — Local infections in- 
volving the mastoid wound may develop at any time subsequent 
to the operation. 

The chief varieties of wound infection are stitch abscesses, 
local abscesses in the surrounding tissues, iodoform dermatitis, and 
erysipelas. 

These complications are for the most part due to surface 
infection from the outflow of pus and the contact of scrapings 
during the operation upon the bone. Stitches should be imme- 
diately removed upon the first appearance of pus, and larger 
abscesses are to be incised and washed out or treated by swabbing 
with pure carbolic acid, followed almost immediately by swabbing 
with absolute alcohol. The latter is employed in order to limit the 
action of the carbolic acid. Simple dermatitis is best treated by wet 
bichlorid of mercury dressings, or dressings which are constantly 
kept moist with Burrows's solution. Erysipelas (see Chapter 
XXXII) is the most serious of the wound complications. 

Results. — The simple mastoid operation when employed in 
suitable cases, and previous to the advent of serious complications, 
yields brilliant results and ranks high among the life-saving surgical 
measures known to medicine. X T ot only does it cure the disease, 
but, when skillfully performed and with its after-treatment properly 
carried out, it restores to normal functional activity the affected 
ear. The mortality from the operation per se is so extremely low in 
comparison with that of the disease when allowed to terminate without 
operation that one can hardlv understand why any opposition to its 
employment should ever arise. The small percentage of deaths 
which follow r the operation are usually from some complication, 
intracranial in nature, upon which the operation itself has no 
bearing, but is of benefit, inasmuch as it affords one step toward 
their cure. 



CHAPTER XXI. 

DISEASES OF THE MIDDLE EAR. 

(Continued.) 



CHRONIC PURULENT OTITIS MEDIA. 

Synonym. — Chronic suppuration of the middle ear. 

Definition. — Chronic purulent otitis media is characterized by 
a chronic inflammatory process arising from various pathological, 
lesions which involve one or more areas of the mucosa and the 
bony structures which comprise the middle ear, the most common 
symptom of which is otorrhea. 

Pathology. — There are divers elements to be considered in 
discussing the pathology of chronic middle-ear suppurations, otitis 
media purulenta chronica being a general clinical term under which 
we group the various pathological lesions. 

1. Changes in the Mucous Membrane. — The mucous mem- 
brane lining the tympanic cavity and its neighboring cells, the 
aditus, the mastoid antrum and the mastoid cells, primarily under- 
goes changes which at first present the characteristics usually 
observed in acute purulent inflammations. At the commencement 
there is a distinct hyperemia of the mucosa, accompanied by a 
small round-celled infiltrate. As the disease progresses new con- 
nective-tissue elements are added, which serve to establish the 
chronicity of the disease as far as the mucous membrane is con- 
cerned. 

The hyperemia now subsides and the membrane assumes a 
paler or grayish color. The extensions of the disease within the 
mucosa are marked by the appearance of excrescences at places, 
and these in turn become true granulations (Fig. 162). The granu- 
lations may take upon themselves distinct characteristics so 
as to become recognized clinically as aural potypi. From their 
histological aspect Steinbriigge 1 classifies them as (a) granula- 
tions of mucous or round-cell type; (b) fibromata; (c) myxomata. 
They may vary in size from being scarcely perceptible to large 
masses which completely fill the tympanic cavity and protrude 
beyond the perforated drumhead into the external auditory meatus, 
occasionally appearing at its outer orifice. 

Since the entire mucous membrane is affected by the pathologic 
lesion, the site from which polypi may arise is extremely variable. 
They may spring from any portion of the interior of the tympanic 
cavity, even from the tegmen or interior of the mastoid process 
(Figs. 163 and 179). They may spring from the borders of the 
perforated drum membrane, and more rarely the site of origin is in 
some portion of the external auditory canal. 



1 Lehrhuch der Ohrenheilkunde, by von Troltsch, 3d edition. 

(253) 



254 THE MIDDLE EAR. 

Aural polypi may be single or multiple (Figs. 165 and 179) . 
They vary in consistence from extreme softness to the hardness of a 
fibroma. Sometimes they are cystic. The surface of the polypus 
may vary from the oval smooth variety to those which are distinctly 
lobulated, and microscopically they show all the transient changes 
from simple epithelium to pavement epithelium. According to 
Brithl, 2 aural polypi contain more than 78 per cent, of granulation 
tissue. 

In themselves, aural polypi give no symptoms except occa- 
sionally when they may cause hemorrhagic discoloration of the 
aural discharge, or when they have attained sufficient size to impair 
the hearing or to impede drainage from the middle ear, in which 
event aural pain may ensue. 

The chief significance of aural polypi lies in the fact that they 
usually indicate a bone lesion in some portion of the middle ear or its 
adnexa. 

The diagnosis of polypi is never difficult. They must be dif- 
ferentiated from congested, bulging drum membranes. The use 
of the probe, which when skillfully handled can be made to pass 
around the growth, settles the diagnosis. The motility of the 
polypi is thus also determined and very often the site of origin 
defined. On the contrary, an inflamed and bulging membrana tympani, 
with the accompanying symptoms of an acute middle-ear inflam- 
mation — notably the otalgia — help to determine the diagnosis. 

Sometimes the inner tympanic wall is mistaken for a polypus, 
especially when there has been complete destruction of the drum- 
head and exfoliation of the ossicles. The employment of the probe 
demonstrates that the suspected area is of bony hardness; further- 
more, Eustachian inflation evokes the characteristic auscultatory 
sound of a large perforation and thereby proves the absence of a 
large polypus. 

Aural polypi are commonly observed in connection with per- 
forations of the drumhead which extend into Shrapnell's mem- 
brane, and also in cases which present perforations marginally 
situated ( Fig. 164). 

The next element entering into the pathology of otitis media 
purulenta chronica is the ingrowth of epithelium from the derma of 
the external auditory canal. The drumhead having been perforated, 
and the continued otorrhea having gradually enlarged this perfora- 
tion to a variable extent, the epidermis either from the external 
layer of the drumhead, or, if the latter is nearly destroyed, from 
the walls of the external auditory meatus, gradually advances inward 
through the perforation and grows over the mucous membrane of the 
tympanic cavity. The dermatized areas are often visible. The 
microscopic examination of the mucous membrane of the tympanic 
cavity shows at the completion of this stage of the disease the 
characteristics of the adjacent derma which lines the external meatus. 
It is due to this process that centrally located perforations of long 



2 Archives of Otology, vol. xxx. 






CHRONIC PURULENT OTITIS MEDIA. 255 

standing occasionally become closed, the derma meeting and sealing 
the perforation. When the drumhead is very much retracted this proc- 
ess is also the factor which causes it to become adherent to the prom- 
ontory, through the spreading of the derma from the edges of the 
perforation to the promontory, thus binding the promontory and drum 
to each other. When the perforation is marginally located the spread 
of epidermis is directly from the external auditory canal wall and the 
ingrowth is of greater vitality. Dependent on the site of the perfora- 
tion, the inward advancing epidermis may enter the epitympanic space 
or the lower part of the tympanic cavity. From a perforation in 
Shrapnell's membrane the epidermis may effect entrance to the 
aditus, eventually reach the mastoid antrum and portions of the 
mastoid process. 

This process has been known clinically as the formation of 
cholesteatoma. The ingrowth does not proceed smoothly, but in many 






Fig. 162.— Large Fig. 163.— Showing an Fig. 164. — Polypus 

granulations in- aural polypus projecting protruding from a per- 

volving the intra- through a perforation in f oration in Shrapnell's 

tympanic mucosa. the drum membrane. membrane. 

places dies off, and the exfoliated epidermis is retained as foreign 
matter and promotes irritation and aggravates the otorrhea. The 
retained secretions are prone to putrefy as a result of the admixture 
of pus, exfoliated epithelium and infection by an endless variety 
of micro-organisms. 

While from a pathological standpoint the ingrowth of epidermis 
is regarded as a process by which nature attempts to cause healing 
(Boenninghaus), yet clinically this process, for reasons, _some of 
which are given above, may cause symptoms requiring radical 
removal of the contents of the tympanic cavity and the mastoid 
process, in order to establish a wide-open intratympanic space. 
This especially is true when the newly formed epidermis des- 
quamates to any degree, inasmuch as the admixture of pus from 
the original site of the disease, and the desquamated epidermis, 
cause the putrid condition so often found upon operation in 
cases of cholesteatoma. Furthermore, even when apparently there 
is free drainage, the pressure exerted by the masses of exfoliated 
epidermis, and the progressive ingrowth of epithelium, causes 
absorption of the bony parts upon which this pseudo-new growth 
is exerting pressure, and the operative findings in some of these 
cases show great destruction of anatomical structures from this cause. 



256 THE MIDDLE EAR. 

If the pus foci now become more active within the middle- 
ear space--, the dry masses of epidermis gather and gradually take 
mi very large dimensions, and likewise exert pressure and produce 
bone absorption. This latter condition is designated pseudo- 
cholesteatoma. 

2. Changes in the Bone. — In chronic purulent otitis media the 
bone lesions observed pathologically, but more especially upon the 
operating table, are as follows: 1. Caries and necrosis. 2. Sclerosis 
(eburnation). 3. Pressure atrophy. 4. Rarefaction of the bone. 

Necrosis and caries of the ossicles and tympanic walls due to 
bacterial action and the resultant changes in the mucous membrane, 
through which the blood-supply of the bone is affected, is fre- 
quently observed in cases of chronic purulent otitis media. The 
same causes, operating to produce changes in the mucous mem- 
brane, are factors in the production of the necrosis or caries. 
Tuberculous and syphilitic infection play a prominent role in the 
production of caries of the ossicles and temporal bone. The 
nutrient blood-vessels gradually become obliterated and, in turn, 
the bone dies, while during the entire process of its disintegration 
the otorrhea continues. 

The caries or necrosis may be confined to the ossicular chain, 
but, as a rule, this process also involves the tympanic ring (annulus 
tympanicus) and other portions of the tympanic walls (Fig. 165). 
In the more severe types the necrotic process extends through the 
aditus, to the mastoid antrum and the mastoid cells. Even the inner 
cranial table and the labyrinth are not exempt, and herein lies one 
of the dangers of this disease. 

Exfoliation of the necrosed areas of bone usually occurs in the 
form of minute masses which flow away in the discharge; but occa- 
sionally large sequestra from the mastoid, the squamous or petrous 
portions of the temporal bone separate, but remain as foreign bodies 
until removed by surgical methods (Fig. 73). 

Sclerosis (eburnation ). — This process is almost always observed 
in cases of long-standing otitis media purulenta chronica. The 
pneumatic cells and the Haversian canals in the bone become 
replaced by compact osseous tissue, which eventually becomes hard 
and of the consistency of ivory. According to Korner, the process 
of eburnation usually begins at the periphery of the mastoid, and 
in the course of years eventually reaches the interior, even to the 
mastoid antrum, and thus the entire mastoid process becomes con- 
verted into compact, eburnated bone. Sometimes, here and there, 
throughout this compact mass, there are large or smaller spaces, 
where the original bony structure is preserved; or, more likely, 
there are purulent tracts running through the sclerosed bone. 

The process of eburnation is regarded by many as a reaction 
of the healthy bone to the irritants of the disease, and, but for 
certain factors hereinafter described, would be a process which 
we would not disturb. Rut because of the tracts of purulent dis- 
ease which run in irregular channels through it, and the likelihood 
of one or other of these being shut off externally by the advance of 



CHRONIC PURULENT OTITIS MEDIA. 257 

eburnation, there is a tendency created to force the purulent foci 
to advance toward the interior; hence, the process of eburnation 
introduces a very troublesome factor into the treatment of chronic 
purulent otitis media. 

Furthermore, since observation has verified the fact that eburna- 
tion takes place from the cortex of the mastoid process, and since 
it advances mesially, rarely occurring along the tegmen cellular, 
tegmen tympani or tegmen antri, it is an etiological factor in the 
invasion of the cranial cavity by the purulent disease originally 
located in the middle-ear spaces. 

Pressure Atrophy. — In the diseussion above of the ingrowth of 
epidermis, we showed how the gradual increase in size of the 
cholesteatomatous masses within the middle ear, by exerting pres- 
sure on the surrounding bony structure, caused the bone to become 
absorbed. 

In examining cases where the process has not been of too long 
duration, this atrophy or absorption of bone is very evident. 
Large or smaller holes are observed in the mastoid process, and 
Boenninghaus claims that in cases of long duration the entire 
mastoid process and temporal pyramid may become excavated 
under the cortex. In such cases if the cortex eventually becomes 
perforated, then the fistulous tract leads to this cavity, which is 
entirely enclosed by bony walls.- An analogy to this process in 
general pathology is found in cases of aneurism of the aorta when 
it presses against the posterior bony thoracic wall and causes bony 
absorption of these walls. (Boenninghaus.) 

Rarefaction of Bone. — This process is quite distinct from the 
bone atrophy and absorption described above. It simulates the 
lesion usually found in acute mastoiditis and pathologically is a 
disease of the bone designated ostitis rareficans simplex. The 
lesion is often found in the immediate vicinity of the antrum and 
tympanic cavity, and is usually surrounded by eburnation. The 
line of demarkation between the eburnated portion and the rarefied 
parts is demonstrable. The rarefied bone is extremely soft and 
usually of a brownish color. Usually all the walls of the antrum 
are involved, but occasionally this process extends in a definite 
tract toward the sulcus sigmoideus, or toward the tegmen. 

The upper portion of the bony posterior wall of the external 
auditory canal is a frequent seat of this lesion, and the necrosis 
or caries of the malleus and incus is generally the result of this 
pathologic lesion. 

3. New Growths. — It is not our purpose in this connection to 
describe the pathology of neoplasms of the middle ear and mastoid 
process. The classification of middle-ear lesions which produce 
otorrhea, and the train of symptoms which we classify as otitis 
media purulenta, would not "be complete were we to overlook the 
fact that the growth of neoplasms, both benign or malignant, is 
capable of producing otitis media purulenta chronica. 

The development of a carcinoma or a sarcoma within the 
tympanic cavity or mastoid process would, by its advance, cause 

17 



258 THE MIDDLE EAR. 

bone absorption and by its desquamation and exfoliated detritus 
produce otorrhea. The use of the probe, the history of the case 
and the involvement of the neighboring glands serve to complete 
the clinical picture of these growths. For a description of neo- 
plasms of the ear the reader is referred to Chapter XIII. 

Etiology. — An attack of acute purulent otitis media or a suc- 
cession of such attacks in which the disease is allowed to progress 
unaided by the established principles of treatment (see Chapter 
XVIII) constitutes the chief cause of chronic suppuration of the 
middle ear. 

In otherwise healthy individuals an attack of acute purulent 
otitis media, even when resulting from some infection of virulent 
type, should terminate in recovery in from three days to five weeks, 
providing the patient is the subject of proper care and is skillfully 
treated according to modern methods, and that purulent mastoiditis 
does not supervene. 

The fact that so large a proportion of all patients who suffer 
from chronic otorrhea are able to associate its commencement with 
an attack of diphtheria, measles, scarlet fever, typhoid fever or 
other grave infections gives emphasis to the etiological relation 
which these diseases bear to purulent otitis media (see Chapters 
XXXI and XXXII). 

The deleterious effects of general infections upon the ear are 
due to the virulence of their characteristic micro-organisms (see 
Chapter V), combined with the physical exhaustion and consequent 
lowered resisting power which follows such attacks. It is probable 
that a considerable proportion of all cases of chronic purulent 
otitis media have been the victims, during the time of the primary 
attack of a complicating acute mastoiditis, from which recovery 
has taken place without operation, but with a persistent offensive 
discharge, loss of hearing and all the dangers which attend a 
chronic purulent necrotic process in the temporal bone. 

In every case of this type a simple mastoid operation (see 
Chapter XIX), promptly and timely performed, would, in the 
majority of cases, prevent these serious sequeke, and preserve the 
hearing. 

Age is no barrier to this disease, but in a large proportion of 
all cases the disease commences during childhood. General con- 
stitutional diseases predispose both to cause and prolong chronic 
otorrhea. 

Thus tuberculosis, syphilis, malignant growths as well as 
diabetes are factors which tend to prolong middle-ear suppuration 
and induce chronicity. 

It has heretofore been asserted as an invariable rule (Chapter 
XVIII) that recurrent attacks of otorrhea in children are indicative 
of the presence of adenoids and hypertrophied tonsils. The same 
rule applies equally to chronic otorrhea occurring in young chil- 
dren, while in older individuals any form of obstruction to nasal 
respiration, and especially new growths and purulent affections of 



CHRONIC PURULENT OTITIS MEDIA. 259 

the nasal accessory sinuses show a marked tendency to prolong 
a purulent otitis media beyond the acute stage. 

The exact point of time when an acute purulent otitis media 
becomes chronic is not clearly definable clinically. The persistence 
of an otorrhea beyond eight to twelve weeks is by common consent 
regarded as chronic. In any case wherein, as a result of some 
constitutional dyscrasia combined with a severe type of infection, 
the pathologic lesions characteristic of chronic purulent otitis 
media are quickly produced, it is possible for the disease to show 
signs of chronicity almost from the beginning. This is especially 
true in tuberculous and syphilitic patients, and to a less degree 
in those who suffer from diabetes, or who are ill nourished and 
anemic from bad hygiene, exposure, serious illness or lack of suffi- 
cient oxygen as a result of adenoids and hypertrophied tonsils. 

Symptoms and Course. — The various pathologic processes 
which are the known causative factors of otitis media purulenta 
chronica are productive of certain symptoms the chief of which are 
otorrhea, progressive loss of hearing and tinnitus. Such symptoms 
as pain, vertigo, nausea, nystagmus and facial paralysis are usually 
indications of complicating lesions and are hereinafter described under 
appropriate headings. 

Otorrhea. — The most persistent symptom associated with chronic 
purulent otitis media is the aural discharge. It may be continuous 
and exceedingly profuse or intermittent and scanty. When profuse 
(otopyorrhea) it flows freely from the external meatus, and if tam- 
pons of absorbent cotton are constantly worn the pledgets soon become 
soaked with the secretion and require changing several times each 
day. When no absorbent cotton is worn the patient is obliged to 
wipe out the external canal at frequent intervals. 

When scant in quantity the discharge may be perceptible only 
as moisture in the canal, or not be observed save on otoscopic ex- 
amination. In this type of otorrhea the minute quantity tends to 
adhere about the borders of the perforation, and finally to form 
inspissated masses which may fill the fundus of the canal. The 
removal of the crusts is usually followed for a short time by a per- 
ceptible otorrhea. 

This type of the disease is often mistakably described as inter- 
mittent otorrhea. It is quite common for the ignorant or neglectful 
mothers of children who have chronic otorrhea to allow the pus to 
flow and accumulate about the external ear and remain undisturbed 
until a dermatitis of the auricle results from the irritation of the 
discharge. 

The secretion from the middle ear may be purulent, mucopurulent 
or be composed of an admixture of pus, blood, disintegrated bone, 
epidermis or cerumen. If of long standing, especially when treatment 
has been neglected, the discharge emits a fetid odor. The latter is 
characteristic of caries or necrosis of the bone. 

Odor also is common in cholesteatomatous otorrhea. The latter 
is peculiarly offensive but quite unlike the carrion-like odor which is 
observed when there is an extensive necrosis of the bones. A large 



260 



THE MIDDLE EAR. 



proportion of those who arc afflicted with chronic purulent otitis media 
evince but little anxiety in regard to the gravity of the disease, and 
look upon it as a trivial though troublesome malady. They seek 
treatment solely in order to overcome the odor, the necessity for 
daily cleansing of the meatus, and the wearing of absorbent cotton in 
the ear. Mucoid discharge is more common when the disease is con- 
fined to the Eustachian tube and the portions of the mucosa surround- 
in."' its tympanic orifice. In this type of the disease the perforations 
in the drumhead are usually in the lower quadrant. 

The appearance of blood in the aural discharge is indicative of 
granulations or polypi, the blood-vessels of which are numerous and 
have thin walls. 

The loss of hearing varies with the progress of the disease, and 
the location of the pathological lesions. There may be extensive 





Fig. 165. — Lateral view, partly schematic, with key plate, (A) 
showing extensive caries of the ossicles (B) and walls of the tym- 
panum (C) and much granulation tissue. 



involvement of both the mucosa and bony walls, but so long as the 
stapes and oval window escape and other labyrinthine complications 
do not occur the hearing may remain good. The loss of hearing may 
be imperceptible to the patient for all practical purposes, or it may 
have reached any intermediate stage, even to a high degree of deafness. 

It is quite common for children who have lost the drum membrane, 
malleus and incus to retain sufficient hearing to enable them to attend 
school and receive instruction with but little inconvenience. On the 
other hand, the disease may be so violent and destructive as to destroy 
the hearing entirely and cause deaf mutism. (See Chapter XXVIII.) 

The degree of persistence of tinnitus also is variable, some patients 
not complaining of this symptom at all, while in others it constitutes 
the most distressing symptom for which they seek relief. Tin- 
nitus is neither so persistent nor distressing as that which occurs in 
non-suppurative middle-ear and labyrinthine affections. Violent 



CHRONIC PURULENT OTITIS MEDIA. 



261 



tinnitus, especially when accompanied by vertigo and nausea, is an 
indication of labyrinthine involvement. 

The three symptoms described above — viz., otorrhea, hardness of 
hearing and tinnitus — constitute the symptom-complex of otitis 
media purulenta chronica. The symptoms change upon the advent 
of complications. Of the occasional symptoms which accompany 
chronic purulent otitis media pain is the most common. The pain 
is often caused by a furunculosis of the external auditory canal 
(Fig. 68) ; or it may result from pus retention in the middle ear, 
brought on by the growth of polypi (Fig. 164), or as a result of 
imperfect drainage from any cause. 

Furthermore, pain in otitis media purulenta chronica may result 
from the swelling of cholesteatomatous masses in the middle ear. It is 
also a characteristic symptom of eburnation of the cells of the mastoid 
process. 





Fig. 166. — Lateral view of the tympanic cavity, with key plate, partly 
schematic, showing (A) the outline of a large perforation in the drum 
membrane, which has healed by the formation of (B) scar tissue. 



Finally, when the disease involves the periosteum — that is, causes 
a periostitis (Fig. 125), or when the intracranial structures become 
involved, pain becomes a prominent symptom. 

Another symptom which becomes prominent when complications 
threaten is vertigo. Dizziness, as we shall see under the appropriate 
chapters, is indicative of labyrinthine or intracranial involvement. 
The symptoms characteristic of acute mastoiditis, sinus-thrombosis 
and intracranial lesions are likewise appropriately described in the 
chapters under their respective headings. 

Course. — The pathologic lesion causing otitis media purulenta 
chronica may be terminated surgically or by local treatment or the 
disease may run its course through the entire life of the patient. 
When terminated by whatever means, except surgically, the perfora- 
tion in the drum may become covered by scar tissue (Fig. 166) and 
the lesion shut off by connective tissue (Fig. 166). or by being 
covered by epidermis. On the other hand a large perforation in the 
drumhead may persist and its borders become covered by epidermis 
or scar tissue, and, furthermore, the exposed mucous membrane of 
the tympanic cavity may become dcrmati/.cd and the suppurative 



262 THE MIDDLE EAR. 

process reach a standstill. Old perforation scars are prone to 
become the seat of calcareous deposits or plaques (Fig. 114). 

The disease may become quiescent for a longer or a shorter time, 
to start up again, following a "cold," an attack of grippe, or one of 
the exanthemata. The recurrence of suppuration is especially 
marked in those with nasal obstruction and adenoid vegetations. 

Finally, the disease may persist through life, without mastoid, 
intracranial or labyrinthine complications; or at any time these 
lesions may appear with serious consequences. 

The most common complication of chronic purulent otitis media 
is an acute exacerbation of the disease, or an acute purulent mastoiditis 
superimposed upon the chronic middle-ear suppuration. Other com- 
plications are those which result in involvement of the dura mater, the 
brain or the labvrinth. 




Fig. 167. — Showing perforation in the drum membrane, which lias healed 
over by connective tissue, leaving a permanent scar. 

Diagnosis. — A priori it ma}' be asserted that a chronic dis- 
charge from the ear usually emanates from the middle-ear spaces. 
Otoscopically, this is manifested more positively when we note the pus 
flowing from the middle-ear spaces through the perforation in the 
drumhead. The pulsation sometimes seen in the otoscopic picture is 
less frequently observed in chronic otorrhea than in the acute form of 
the disease ; yet as a diagnostic sign that the pus emanates from the 
middle ear this symptom must be remembered. 

Fxact diagnosis that the chronic otorrhea is due to a suppuration 
within the tympanic cavity depends upon seeing the perforation in the 
membrana tympani, and the observation of pus coming through the 
perforation. Exostosis of the external auditory canal, furunculosis 
and all other lesions of the external auditory canal must be excluded. 

There are certain obstacles which tend to obscure the inspection 
of the drumhead. Chief among these are exostoses of the external 
auditory canal walls (Fig. 97), tumors (Fig. 67), or polypi (Fig. 179), 
which occlude the canal lumen and prevent a distinct view of the drum. 
The outlines of perforations often become obscured by masses of 
exfoliated cholesteatoma or inspissated pus. In doubtful cases the 
use of the Eustachian catheter, whereby the auscultation sound of a 
perforation is obtainable, helps to clear the mooted point. 

Boenninghaus recommends, in cases where there is doubt as to 
tbe presence of a perforation even after inflation, that the end of the 
auscultation tube be immersed in a class of water and the inflation 



CHRONIC PURULENT OTITIS MEDIA. 



263 



repeated. If a perforation emits air which escapes into the auditory 
canal and thence into the auscultation tube, it will escape through the 
water and cause bubbles. 

The employment of a probe, tipped with cotton, will show moisture 
in cases where the secretions are scant and scarcely discernible to the 
eye, and the use of the Siegel otoscope in disturbing the secretions 
is also of service in rendering a diagnosis. 

The diagnosis of the ingrowth of epidermis, or rather the 
presence of cholesteatomata, depends usually upon obtaining the 
epidermis scales in the examination of the ear discharge. The 
pus is usually of a very foul odor, and the flakes are more particu- 
larly to be seen in the region of Shrapnell's membrane, from 
which they may be loosened by the use of a probe or ring curet. 
The dry or pseudo-cholesteatoma is usually diagnosticated by a 





Fig. 168. — Lateral view of tympanic cavit}', with key plate, partly 
schematic view, showing (A) large perforation in drumhead, (B) necro- 
sis of promontory and (C) large polypus protruding into the external 
auditory canal. 

microscopical examination of the scales obtained from the canal. 
Caries and necrosis of the malleus (Fig. 172), and sometimes a 
large sequestra lying in the middle-ear space may be visible to the 
eye, but a positive diagnosis depends upon a skillful use of the 
probe. The Hartmann probe (Fig. 3), being of small calibre and 
made of silver, is flexible and, when bent in various short curves 
and angles, permits the surgeon to explore a considerable area of 
the tympanum proper and the epitympanic space. When intro- 
duced through the perforation and manipulated in various direc- 
tions, the necrosed ossicles and exposed tympanic walls can be 
felt as rough areas and even sequestra can both be felt and moved. 

The odor from aural necrosis is carrion-like and characteristic. 
The presence of polypi is significant of bone necrosis (Fig. 168), 
especially when they recur quickly after being removed, even 
though the patient is under constant local treatment. 

Finally, the location of the perforations in the drumhead is of 
considerable diagnostic significance in chronic purulent otitis 
media. Broadly speaking, perforations of small or medium size 
which are located in 'the drum membrane proper and which do not 



264 



THE MIDDLE EAR. 



impinge upon the contiguous bony structures at any point (Fig. 
169) indicate that the disease is confined to the mucosa of the 
middle-ear spaces, and that the bone has not yet become affected. 

This rule is not invariable, as in a small proportion of centrally 
located perforations there is found a continuous flow of foul-smell- 
ing pus and protruding granulations which bear evidence of bone 
necrosis. 

Another type of perforation observed in cases of chronic 
purulent otitis media is one which involves the long process of 
the malleus in varying degrees. A single perforation involving the 
distal extremity of the malleus handle is shown in Fig. 170, 
while one of larger size with granular edges, and showing some 
loss of the malleus handle through necrosis is illustrated in Fig. 
171. 




Fig. 169.— Perfora- 
tion of the drum 
membrane which 
does not impinge 
upon the bony struc- 
tures of the middle 
ear. 




Fig. 170. — Small per- 
foration at the umbo. 
The distal end of the 
malleus handle is ex- 
posed and necrotic. 




Fig. 171. —Perforation 
of large size in central 
portion of the drumhead. 
The edges are granular 
and the tip end of the 
malleus handle has 
sloughed away. 



In a third type of perforations the destruction of the drum- 
head is extensive, with more or less complete loss of the ossicles 
from necrosis (Figs. s 172 and 173). In these cases the visible 
necrosis usually represents but a small portion of the actual extent 
of the disease. 

A fourth type may be defined as multiple perforations. These 
may be large (Fig. 174) or small (Fig. 175), and are, as a rule, 
indicative of tuberculosis or syphilis. 

A fifth type, wherein the perforation is located high up within 
the confines of Shrapnell's membrane (Fig. 176) with destruction 
or visible necrosis of the ossicles, furnishes presumptive evidence 
of more or less extensive disease of the bony walls of the attic, 
aditus and mastoid antrum. These are prone to permit the ingrowth 
of epithelium from the external auditory canal, in which event there 
is added the dangers of cholesteatomata. This is considered a 
dangerous type of perforation on account of the extensive and 
far-reaching necrosis which usually accompanies it. Furthermore, 
perforations through Shrapnell's membrane, together with other 
marginal perforations, to be hereinafter considered, furnish a larger 



CHRONIC PURULENT OTITIS MEDIA. 



265 



proportion of cases requiring the radical mastoid operation than 
those which are centrally located. 

A sixth type of perforation is that which is located at the 
margin of the drum membrane proper (Fig. 177), with or without 
the presence of protruding granulations (Fig. 163). They vary in 
extent and may involve any quadrant of the drumhead at its per- 
iphery. When accompanied by continuous fetid discharge, this 
type of perforation gives evidence not only of necrosis of the 
underlying bone in the immediate vicinity, but of other portions of 
the middle-ear spaces. The pus in chronic purulent otitis media 
usually contains a mixed infection, which indicates chronicity. 
(For the Bacteriology of Middle-ear Discharges see Chapter V.) 

In conclusion, the diagnosis of chronic purulent otitis media is 
based upon : — 





Fig. 172. — Loss of ths entire cen- 
tral portion of the drum mem- 
brane and small portion of the 
membrana flaccida. The malleus 
handle is necrotic and the incus is 
destroyed. 



Fig. 173. — Almost entire absence 
of the drumhead proper and the 
membrana flaccida. The entire 
incus and nearly the entire malleus 
have succumbed to the necrotic 
process. The stapes remains intact, 
and the round window is visible. 



1. A history of chronic otorrhea. 

2. The otoscopic findings : (a) Pus in the external auditory 
canal and tympanum, (b) Perforation of the drum membrane. 
(c) Granulations or polypi which spring from the walls of the 
middle-ear spaces, (d) Necrosis of the ossicles and bony walls of 
the middle ear, which is determined by probing and by the presence 
of malodorous pus. 

Prognosis. — (a) Regarding cure of the purulent process, (b) 
Regarding improvement in the hearing, (c) Regarding life. 

Regarding the Cure of the Lesiox 1 . — The much-to-be-desired 
cure of the otorrhea is always dependent upon the nature and 
extent of the ulceration and necrosis of the middle-ear cavities. In 
cases wherein the disease is localized within areas which are acces- 
sible to treatment, especially where bone necrosis is slight in extent 
or absent altogether, a cure of the otorrhea may be expected after a 
reasonably short season of local treatment. Furthermore, in those 
cases which have been neglected or indifferently treated, marked 
improvement usually follows the establishment of the local 
measures of treatment hereinafter described. 



266 THE MIDDLE EAR. 

But necrosis, wherever located, becomes a serious obstacle to 
cure by local measures. When confined to the ossicles "and annular 
ring it is sometimes possible to effect a cure after a prolonged 
period of local treatment, especially when aided by improved general 
health and -consequent increased bodily resistance. Extensive 
necrosis with profuse malodorous discharge and proliferating 
granulations does not usually yield to local measures of treatment, 
but requires radical surgical intervention in order to eradicate the 
disease. Otorrhea sometimes persists even after the most skillful 
and painstaking radical operations, but such cases are exceptions 
to the general rule. 

Regarding the Hearing. — It may be stated that as a general 
rule chronic purulent otitis media diminishes the hearing function 
in varying degrees. There are rare exceptions wherein a prolonged 
suppurative process in and about the middle-ear cavities does not 





Fig. 174. — Multiple perforations Fig. 175. — Multiple perforations 

in the drumhead. in the drumhead. 

result in any perceptible hearing defect. It is strange that in such 
cases the oval window in its relation to the stapes has entirely 
escaped the ravages of the disease. 

Again, extensive destruction of the drum membrane may take 
place without loss of hearing. The necrotic process may extend 
even farther and destroy the malleus, the incus and portions 
of the annulus tympanicus, but so long as the stapes remains 
movable in its normal position the hearing may not become 
seriously impaired. 

Unfortunately, the final healing of the purulent process within 
the middle ear is prone to eventuate in adhesions, especially around 
the oval and the round windows, and serious impairment of hearing. 
Furthermore, labyrinthine suppuration, even when recovered from, 
is usually followed by loss of the hearing function. 

It is also true that a considerable proportion of patients who 
suffer from otorrhea hear better while the discharge persists than 
they do after the discharge has ceased. This is largely due to the 
ultimate thickening of the mucosa of the middle ear, to retracting 
cicatrices and adhesions of the ossicles. 

Total deafness as a result of chronic purulent otitis media is 
rare. The more reliable statistics relative to the results upon the 
hearing in the radical operation performed for the cure of this 



CHRONIC PURULENT OTITIS MEDIA. 



267 



disease are not unfavorable in the main. In 75 cases reported by 
the author 3 the hearing- was improved in 28, unchanged in 25, and 
impaired in 22. 

Regarding the Life. — While the fatalities which result from 
chronic purulent otitis media are proportionately few in number, 
they occur with sufficient frequency to necessitate our classifying 
this disease among those which are hazardous to life. Bone 
necrosis is the danger signal of chronic purulent otitis media. 
Fatalities from this cause occur as a result of gradual extension of 
the necrotic process through the attic or antrum tegmen, through 
the labyrinth, through that portion of the inner wall of the mastoid 
process which covers the lateral sinus, through other portions of 
the mesial or cranial wall, or from softening or absorption of the 
bony tissues from retained cholesteatomatous masses. In this 
manner the infection which heretofore has remained localized within 




Fig. 176. — Large perforation in 
Shrapnell's membrane, through 
which the carious malleus and 
incus are visible. A portion of the 
outer wall has been destroyed from 
necrosis. 




Fig. 177. — The perforation here 
shown is the upper posterior quad- 
rant at the junction of the drum 
membrane proper with Shrap- 
nell's membrane. 



the middle-ear cavities is permitted to invade the meninges. Death 
is thereby caused by purulent meningitis, cerebral abscess, cerebellar 
abscess, or by pyemic thrombosis of the lateral sinus and internal 
jugular vein. Barring traumatisms and systemic infections like 
epidemic cerebrospinal meningitis, purulent inflammation of the 
middle-ear spaces remains the chief source of all intracranial 
infections. 

Finally, as a more detailed statement of prognosis, we find the 
prognosis to be good, from the clinical standpoint, when the case 
is not of long standing and is uncomplicated by granulations, when 
the otorrhea is not fetid, and is mucopurulent in character. The 
prognosis is worse when the otorrhea is fetid, when complicated 
by granular excrescences or polypi, when the perforations in the 
drumhead are marginally situated, and when the epidermis has 
invaded the tympanic cavity. 

Treatment. — The treatment of chronic purulent otitis media 



3 Transactions of the American Laryngological, Rhinological, and Oto- 
logical Society, 1909. 



268 THE MIDDLE EAR. 

is properly classified under the following general headings, depend- 
ing upon the duration of the disease and the location and extent of 
the pathological lesion: 1. Local therapy. 2. Intratympanic opera- 
tion (ossiculectomy). 3. The so-called radical mastoid operation. 
1. Local Therapy.— Of the three methods the simplest is that 
known as local treatment. This is applicable to and usually suc- 
cessful in a considerable proportion of cases of chronic otorrhea. 
The type of cases amenable to local treatment may be defined as 
the simple variety, wherein the soft tissues only are involved, or 
where the bone necrosis is localized, and in those where the disease 
is aggravated by adenoids, hypertrophied tonsils, lack of cleanli- 
ness, proper nourishment and hygienic surroundings. Here the 
removal of diseased tonsils and adenoids (see Chapters XLIII and 
XLVI), the establishment of right habits and methods of living, 
internal treatment with tonics and local treatment by modern 
methods will usually effect a cure. Primarily the local treatment 
should aim to remove accumulations of pus from the tympanic 
cavity and external auditory canal and to promote the rapid 
drainage of pus. 

Some writers have recommended the dry treatment. In this 
the external auditory canal is cleansed of all removable secretions' 
the site of the perforation is wiped clean, and as much of the 
secrtion as is possible to remove is wiped awav from the tympanic 
cavity through the perforation. A sterile strip of plain gauze is 
then introduced into the canal, pushed up close to the drum and 
left in situ for twenty-four hours, when the entire process is 
renewed. We have had favorable results with this method in acute 
cases, but do not recommend it in the chronic ones. In some of 
the European clinics it has, however, been warmly advocated. 

Methods of Douching. 4 — The cleansing of the purulent cavity by 
means of the douche or syringe is best accomplished by the employ- 
ment of sterile normal salt solution. If large masses of dried 
secretion are found clinging to the walls of the cavity their removal 
is facilitated by previous instillation of a few drops of dilute 
hydrogen peroxid. If necrosis is present bichlorid of mercury 
solution, varying in strength according to the age of the patient, 
may be employed. These solutions should be warm, the tempera- 
ture varying from 100° to 110° F., and should be employed at least 
three times a day. From one to two quarts of such solution in a 
fountain syringe, hung high up in order to give sufficient force to 
the stream, will serve to wash out the external auditory canal, and, 
when large perforations are present in the tympanic cavity, a more 
effective method of douching is that devised by Fowler (see 
Chapter ATT I, Figs. 44, 45 and 46). 

_ It often becomes necessary to irrigate the tympanic cavity and 
attic and this can be accomplished by using a slender glass or metal 
attic cannula (Fig. 178), slightly curved upward at the tip and 
carried through the perforation. The cleansing solution is then 
gently forc ed through the cannula by means of 'a syringe. 

4 For details regarding the ear douche see Chapter VIII. 



CHRONIC PURULENT OTITIS MEDIA. 269 

When the discharge is very fetid the following has been of 
benefit : — 

IJ Formalin ni.v. 

Hydrargyri gr. % 2 . 

Alcohol Sss. 

Aqua dest q. s. ad oiij. 

M. et Sig. : Gtt. v in ear ten minutes before douching. 

After douching there usually remain shreds of mucus or pus 
and other detritus, which must be carefully wiped away with the 
cotton-tipped probe. Any needed intratympanic application may 
now be made. The success of this method of treatment depends 
largely upon the frequency and thoroughness with which local 

■""i»,i//f//y////////////////y/////////// i ,, ////j////; 




An attic cannula in position. 



therapeutic measures are employed. This treatment cannot be 
fully trusted to the mother and rarely even to the nurse, but the 
physician himself must not only examine the ear, but also personally 
administer the local treatment almost daily for long periods of time. 

If granulations recur applications of absolute alcohol or strong 
solution of nitrate of silver produce favorable results. Small areas 
of necrosis should receive frequent applications of nitrate of silver 
or iodin until the necrotic areas slough away. 

In order to facilitate the flow of pus it may become necessary 
to remove or otherwise destroy exuberant granulations, or to 
enlarge the perforation. 

AYhile insufflations of powders have had the recommendations 
of Bezold (boric acid), Spira, Passow (xeroform), and others, we 
believe that the insufflation of powders may cause "caking" when 
they become mixed with the ear discharge and thus retard the flow 
of pus. We do not recommend these powders excepl in the very 
last stages of suppuration, when the ear is almost dry and any 
likelihood of "caking" and pus retention has ]>;i-;srd, and even then 
the amount of powder inserted should be small. 



270 



THE MIDDLE EAR. 



Boenninghaus recommends the use of nitrate of silver 6 per 
cent, solution in alcohol for applying to the ulcerated surfaces. 
Schwartze employs nitrate of silver in those cases where the 
mucous membrane is shown to be much swollen and red. He uses 
solutions beginning with 2 per cent, and ranging as high as 10 per 
cent. The higher percentages are useful in checking polypoid 
excrescences of the mucous membrane. 

Obstructing polypi or granulations should immediately be 
removed. When of sufficient size a small snare (Fig. 179) may be 
employed, otherwise the most effective method is to fuse a small 
crystal of chromic acid upon the end of a probe and plunge it into 
the granulation mass. 

The common occurrence of aural polypi in conjunction with 







¥*&&i&tir -*-" 


* 


: / 






t / 



Fig. 179. — The snare has been passed along the polypus, the mass 
meanwhile being engaged within the wire loop. The pedicle is about to 
be severed at its exit through the perforation in the membrana tympani. 



chronic purulent otitis media renders necessary a brief description 
of the technique of this useful procedure. 

Removal of Aural Polypi. — Coming to the intratympanic operations 
the most frequent procedure is the removal of polypi or granula- 
tion tissue. The presence of polypi or granulation masses in the 
tympanic cavity and external auditory canal almost invariably 
indicates a chronic purulent process in the tympanic cavity and its 
adnexa. The most common attendant symptom is otorrhea. 

This tissue is adventitious and should be removed or otherwise 
destroyed. When accompanied by offensive discharge and by 
extensive bone necrosis some form of operation must be combined 
with it which not only will remove the polypi, but obliterate the 
necrosed tissue as well. A simple method of removing large polypi 
is by means of a small aural snare (Fig. 179). By this procedure 
the projecting portion of the mass is easily cut away. The remain- 
ing base is then cauterized, preferably with a bead of chromic acid 
fused upon the end of a probe. The latter alone is usually sufficient 



CHRONIC PURULENT OTITIS MEDIA. 271 

for the destruction of small granulation masses. In this manner 
the obstructing lesion is removed, but, unfortunately, inasmuch 
as these growths result from an underlying necrotic process, the 
proliferations -are prone to recur, and recurrence is usually rapid. 
It is sometimes necessary to limit the action of the chromic acid by 
douching the ear with salt solution. 

Recurrent proliferations of aural polypi, in cases wherein all 
improved methods of local treatment have been faithfully carried 
out during the interval, indicate a chronic purulent process with 
bone necrosis which involves the spaces which are accessory to the 
tympanic cavity proper, for the cure of which the radical mastoid 
operation becomes imperative. 

It will thus be seen that, while the results of removal by snare 
or destruction with escharotics are favorable in the simple cases 
wherein the disease is confined to the borders of the drum mem- 
brane perforations or portions of the tympanic walls, the results 
are unfavorable and almost invariably attended with recurrence 
when the necrosis is extensive, deep-seated or located in the adnexa, 
the latter cases always requiring the more radical procedures in 
order to effect a cure. 

It occasionally happens that the large polypoid masses which 
project into the external auditory canal spring directly from the 
exposed dura mater or lateral sinus, in which event removal by 
pulling or tearing is attended with considerable danger to the 
meninges. 

Dench has reported a fatal outcome from the intrameatal 
removal of polypi. It was found at the autopsy that in the absence 
of the attic tegmen the polypus had been removed from its attach- 
ment to the dura. It is therefore to be borne in mind that the 
patient should be kept under close observation for some time fol- 
lowing the removal of polypi with the snare. 

The instillation of alcohol (95 per cent.) is indicated in cases 
of cholesteatoma. Aqueous solutions cause the cholesteatomatous 
masses to swell, and add to the discomfort of the patient. The 
alcohol seems to loosen the masses, and permit their removal. 

In the case of polypoid granulations the alcohol also seems to 
have beneficial action, causing dehydration and shrinkage. The 
treatment must be continued for weeks to be fully effective. 
Orthochlorophenol applied to granulations followed by an alcohol 
instillation has also given excellent results. 

At each sitting, in addition to ordinary douching, a careful 
otoscopic examination should be made and all remains of pus and 
detritus carefully wiped away. Inflation in chronic cases is often 
beneficial, the air douche forcing retained secretions from the 
Eustachian tube into the tympanic cavity. In the majority of cases 
it is advisable to continue the local measures above described for a 
considerable period of time, even for months, providing any reason- 
able measure of improvement warrants delnv in operative pro- 
cedures. The results obtained prove the merits of the method, as 
considerably more than 50 per cent, of all cases are cured, or at 



272 THE MIDDLE EAR. 

least sufficiently improved to practically remove the dangers attend- 
ing the chronic purulent process. 

In a case progressing favorably in the course of time the ear 
becomes dry, the perforations may become cicatrized, and healing is 
thus effected. 

If the perforation margins are thickened and covered with 
epidermis the perforation will not heal. An application of trichlor- 
acetic acid removes the epidermis and the perforation margins 
may granulate sufficiently to heal the lesion in the drum. The 
drug is applied every eight days. 

Naturally we only hope to close the perforations when they are 
small and are centrally located. Blake advocates the placing of 
small disks of paper over the perforations in order to effect healing. 
. After the cessation of the discharge, the physician's next duty 
requires him to try to improve the patient's hearing. The cautious 
use of inflation, and some massage to the ear by stretching the 
adhesions, accomplishes much. In many cases the hearing is not 
capable of being improved, and Toynbee, Gruber and others have 
found it advantageous to employ artificial eardrums in these cases. 

In a limited proportion of cases improvement results from the 
use of the various eardrums or from small pledgets of moistened 
cotton fitted into the perforation. Their employment for this 
purpose is always attended with danger of infecting the surrounding 
tissues. 

Unfortunately, the local measures above described prove insuffi- 
cient when extensive necrosis exists, and some form of operative 
treatment must be instituted in order to eradicate the disease. 

Two general methods of operation are valuable, either one of 
which must be decided upon according to the exigencies of the case. 
The first and simpler operation is the intratympanic, which is per- 
formed through the external auditory canal. This operation is also 
termed ossiculectomy. The latter term is objectionable because it 
relates only to the removal of the ossicles, whereas the actual 
operation often requires the curetment of areas of necrosis in the 
attic, annular ring and Eustachian orifice. The second is the so- 
called radical mastoid operation, which is performed externally by 
the postauricular route. 

2. Intratympanic Operation (Ossiculectomy). — The intra- 
tympanic operation or ossiculectomy is simpler in technique, avoids 
external incision, deformity and prolonged and painful dressings. 
While it requires much skill and an accurate knowledge of the 
anatomical surroundings, it is much less formidable than the radical 
mastoid operation. It is necessarily limited in scope to the m'em- 
brana tympani, soft tissues of the tympanic cavity proper, the 
ossicles (malleus and incus only), tympanic ring and walls. Never- 
theless, it is worthy of trial in cases where it can be fairly accurately 
demonstrated that the necrosis is confined to these locations. An 
ossiculectomy, skillfully performed, with the curettage of all 
necrosed areas within reach, will in a somewhat limited percentage 
of cases effect a cure, and even when a complete cure is not effected 



CHRONIC PURULENT OTITIS MEDIA. 



273 



the removal of the membrana tympani and ossicles opens a wide 
channel for the flow of pus from the deeper structures. It is a well- 
known surgical axiom that large openings into pus cavities materi- 
ally aid nature's efforts at repair. 

The author has repeatedly succeeded in terminating a suppura- 
tive process in the middle ear by resorting to this method of treat- 
ment. It is somewhat difficult to define the class of cases in which it 
may be employed with a reasonable hope of success, on account of the 
obstacles in the way of positively determining whether the necrotic 
process is confined to areas within reach ; and yet the history, the 
amount and character of the discharge, and the intelligent use of 



^»^^^^ /7/ 




Fig. 180. — A hypodermic 
needle, introduced along the 
upper portion of the osseous 
canal wall for the purpose of 
injecting a local anesthetic. 



the probe become valuable adjuvants in deciding whether or not 
ossiculectomy is indicated. All patients when advised to submit to 
this operation should be informed that it may fail to cure and that 
the more radical operation may subsequently become necessary. 

3. The Operation. — Ossiculectomy is an operation by which 
the remaining portion of the drum membrane and ossicles is 
removed, together with the curetment of granulations and such 
diseased portions of the tympanic walls, the attic with its outer 
wall, and the annular ring, as may be reached through the external 
meatus. This operation is employed as a means of curing chronic 
purulent otitis media by the removal of diseased tissue and the 
promotion of drainage, and for rendering the tympanic walls more 
accessible to local treatment. It is an intermediary between the 
non-operative method of treatment and the radical mastoid opera- 
tion. 

Indications. — This operation is indicated: 1. When a purulent 
inflammatory process in the middle ear docs not respond to local 
measures of treatment in cases wherein the diseased process is 

is 



274 



THE MIDDLE EAR. 



chiefly confined to the drum membrane, ossicles, and the tympanic 

walls. 

2. After recurrence of polypoid proliferations, unless such 
recurrence is associated with evidences of extensive necrosis in the 
aditus, mastoid antrum, or labyrinth, clinical evidences of which 
are: continued discharge with foul odor; perforations in Shrapnell's 
membrane, or along the upper posterior walls of the tympanic 
membrane; pain in the mastoid region; vertigo, nausea and 
vomiting. 

3. As a preliminary to the radical operation, either on patients 
who never have given evidences of complicating lesions, and in 
whom it is hoped that improved drainage and subsequent persistent 
local treatment will effect a cure of the disease ; or in patients who 




Fig. 181.— A schematic draw- 
ing representing the field of the 
intratympanic operation. A, 
The circle represents the visi- 
ble field. B, The round window. 
C, Footplate of the stapes in the 
oval window. D, The incus. 
E, The malleus. F, The Eusta- 
chian orifice. 




Fig. 182.— Circle A represents the 
outer extremity of the aural specu- 
lum, introduced into the external 
auditory canal. The dotted circle 
B represents the drumhead which 
is to be incised. The small inner 
circle C indicates that portion of 
the drum membrane visible to the 
eye of the operator at one time. 



demand a preliminary operation rather than submit to the more 
formidable procedure except as a last resort. Proportionately, the 
number is not large. 

The operation is performed as follows : Douche the ear thor- 
oughly with a 1:3000 solution of bichlorid of mercury. The anes- 
thesia may be either general or local, the latter being quite feasible 
except in young children and adults of extremely nervous tempera- 
ment. The local anesthetic must be used by means of the hypo- 
dermic needle. A few minims of a solution composed of cocaine, 
one-half of 1 per cent., and adrenalin 1 : 5000 and injected into the 
upper external canal wall at a point close to the drumhead (Fig. 
180) will usually produce the required anesthesia. A few minims 
of a strong solution of cocaine (10 per cent.), when instilled through 
the perforation into the tympanic cavity twenty minutes before the 



CHRONIC PURULENT OTITIS MEDIA. 



275 



injection above mentioned, is of material benefit. An aural speculum 
of Large size is then introduced under bright illumination. The 
visible operating field is represented by the oval line A in the 
accompanying illustration (Fig. 181). In looking at the operative 
field through the aural speculum, the operator can see only one 
segment of the field at a time and is therefore obliged to tilt the 
speculum at various angles during the operation. One visible field 
is thus shown by the tissues included in the dark circle in the illus- 
tration (Fig. 182). 

The first step in the operation consists of severing the entire 
drum membrane from its peripheral attachment by means of a 




Fig. 183.— The pri- 
mary incision to sev- 
er the drumhead 
from its peripheral 
attachments. 




Fig. 184. — The tenotomy 
knife introduced into the tym- 
panic cavity at a p^int above 
the level and behind the 
short process of the malleus, 
for the purpose of severing 
the tendon of the tensor tym- 
pani muscle. 




Fig. 185.— The po- 
sition of the tenot- 
omy knife after the 
tendon of the tensor 
tympani has been 
severed. 



circular incision (Fig. 183). As a rule the detached drumhead will 
cling to the malleus handle and may be removed with that body. 
The incision in the drum is succeeded by the introduction of a small 
angular tenotomy knife at a point just above and posterior to the 
level of the short process of the malleus (Fig. 184). The blade is 
then carried directly downward along the posterior surface of the 
malleus handle, thus severing the attachment of the tensor tympani 
muscle (Fig. 185). The body of the malleus is then firmly grasped 
between the jaws of the extracting forceps (Fig. 186). Traction is 
then made upon the malleus after the manner followed when using 
the traction obstetric forceps in child delivery. 

It is unnecessary to sever the incudostapedial joint for the 
reason that, in extracting the incus, the hook is introduced posterior 
to that body and rotated forward and downward, during which 
manoeuvre its long process separates from the head of the stapes 
without injury to the latter (Fig. 187). 



276 



THE MIDDLE EAR. 



After removing the ossicles, all necrosed surfaces within reach 
are curetted by means of straight and curved curets and biting 
forceps ( Fig. 188). The Kerrison or Hartmann chisel-forceps are 
effective in removing the outer attic wall ( Fig. 189). 

It is important that any granulations located in the vicinity of 
the tympanic orifice of the Eustachian tube should be thoroughly 
curetted. Furthermore if necrosis is discovered underneath these 
granulations the diseased area of bone should be curetted. Having 
completed the required operative procedure, the middle-ear cavity 
should be thoroughly douched with warm normal saline solution, 
and all fragments of bone or other adventitious tissue washed away. 
'Flie surfaces are then thoroughly dried and a narrow strip of iodo- 
form gauze is introduced in such a manner that the epitympanic 
space is filled, and also that the packing presses firmly into the 




Fig. 186.— The angular extracting for- 
ceps have been introduced into the tym- 
panic cavity and are firmly grasping the 
malleus, preparatory to its removal. The 
small sketch represents the lateral view 
of the traction forceps in pjsition. 




Fig. 187. — The illustration 
shows the position of the incus 
hook when introduced for the 
purpose of rjtating the incus 
downward and forward, prepar- 
atory to its removal. 



tympanic orifice of the Eustachian tube. The remaining portion 
of the tympanic cavity is then loosely packed and the external 
canal lightly packed with plain gauze. A pad is then placed over 
the entire ear and the ordinary mastoid bandage applied (Fig. 
157). This dressing should be allowed to remain in situ for forty- 
eight hours. Dressings applied in this manner insure the freshly 
denuded areas within the middle ear against any new infection. 
Furthermore, the drainage of the parts is rapidly absorbed directly 
into the dressings, and not allowed to accumulate in the irregular 
cavities of the middle-ear spaces. It is advisable to repeat this form 
of dressings at the daily visits during the first week, after which 
time the treatment should be followed in a manner similar to that 
which lias been heretofore advised for chronic purulent otitis 
media. 

It is a favorable indication when the first dressings are found 
to be free from pus and offensive odor. There is usually more or 



CHRONIC PURULENT OTITIS MEDIA. 



277 



less discharge for from one to three weeks', but, if the discharge 
gradually becomes thinner and less in quantity, a favorable out- 
come may be expected from the operative procedure. 

On the other hand, whenever the discharge continues to be 
profuse after the intratympanic operative procedure, the continued 
suppurative process becomes an indication of more extensive and 
far-reaching disease of the temporal bone, and one which may be 
expected to yield only to the radical mastoid operation. 



o 



f > ( V ^ 



b aft = * ', [> ? :T»> '.'.' fc ^ "-T " 



Fig. 188. — A, sharp ring curets. B, Angular sharp curets. 



The intratympanic operation is occasionally followed by small 
regrowths of granulations, which develop during the process of 
healing. These should be immediately destroyed, preferably by the 
application of chromic acid. The complete removal of the drum- 
head, outlined in the foregoing description of the operation, favors 
an ingrowth of epithelium from the external canal, which may 
gradually dermatize the surfaces of the tympanic cavity. 

From this time on the middle ear performs its functions with- 
out a drumhead. Individuals thus affected are prone to attacks of 
middle-ear discharge after sea-bathing. They should therefore be 
warned to pack the external auditory canal before entering the 
water. 

The Results. — Tn the author's experience the results have been 
favorable in a considerable proportion of all cases operated upon. 



278 



THE MIDDLE EAR. 



In carefully selected cases of localized chronic otorrhea with large 
perforations of the drum membrane proper, which furnish no 
history of recurrent mastoiditis, the results have been good, com- 
plete recovery being the rule. By recovery is meant a cessation of 
otorrhea. 

The removal of the tissues above mentioned improves the 
drainage from the tympanic cavity, attic and the mastoid antrum. 
Hence, even though the otorrhea may continue, the establishment 
of drainage tends to lessen the complicating dangers of the disease. 




Fig. 189. — Kerrison chisel forceps in position for removing the outer wall 
of the aditus (attic). 



In addition, the operation renders the intratympanic spaces more 
easily accessible to subsequent treatment. 

The operation is not wholly without danger. The facial nerve, 
denuded of its bony covering in the region of the labyrinthine 
(mesial) wall of the tympanum, may be injured during the opera- 
tion, with resultant facial paralysis. Dehiscences over the jugular 
bulb sometimes lead to injury of the blood-vessels at these points, 
with serious consequences. Curetment of polypoid proliferations 
from the parietal surface of the dura, in cases where the tegmen has 
become destroyed by necrosis, has been known to cause serious 
meningeal involvement. 

The chorda tympani nerve, which runs in the posterior fold of 
the drum membrane, is often severed, with resultant temporary 
derangement of taste on the corresponding side of the tongue. 



CHAPTER XXII. 

■ DISEASES OF THE MIDDLE EAR. 

(Continued.) 

CHRONIC PURULENT OTITIS MEDIA. 
The Radical Mastoid Operation. 

Indications. — Briefly stated, the purpose of the radical mastoid 
operation is to convert the external auditory canal, tympanic cavity, 
aditus ad antrum, mastoid antrum and mastoid cells, when dis- 
eased, into one wide-open cavity ; to excavate all granulations and 
diseased bone, to destroy all membranous and muscular tissue lying 
within these limits, including the membrana tympani, and to effect 
dermatization throughout the entire area, in the hope that by so 
doing the ramifications of the disease will be terminated once and 
for all. 

While the general statement that the radical mastoid operation 
is performed in order to effect a cure of chronic purulent otitis 
media is correct, it must be understood that it is not indicated when 
the disease is confined to the tympanic cavity proper, but it is to be 
performed,only when the typical indications which we are about to 
define are present. 

The operation is a capital one, requiring extensive dissection in the 
most complicated bone in the human body. 

The radical mastoid operation is indicated: 1. When a permanent 
cessation of the purulent process has not been effected by prolonged 
local intratympanic treatment, combined if necessary with such minor 
operations as removal of granulations, enlarging perforations, etc. 2. 
When a cure has not been effected by the removal of necrosed ossicles 
and the curettage of the middle ear. 3. When acute symptoms of 
mastoiditis supervene in otitis media purulenta chronica. 4. When a 
sudden cessation of the pus discharge is followed by chills, fever, 
vertigo, pain or other unusual symptoms. 5. The appearance of 
facial paralysis during the course of chronic purulent otitis media. 
6. Attacks of vertigo, nausea and vomiting, indicating that the 
necrotic process involves the labyrinth. 7. In all cases of com- 
plicating intracranial or lateral sinus involvement, the latter being 
characterized by symptoms of general sepsis, increase of leucocytes 
and of polynuclear percentage. 8. When there are positive symp- 
toms of cholesteatoma in the mastoid antrum. 9. When there are 
fistulous openings in the cortex of the mastoid process or in the 
osseous canal wall. 10. Whenever extreme depression or other 
svmntoms of disturbed mentality accompany the disease. 

Contraindications. — The operation is contraindicated : 1. 
./hen the purulent process is tuberculous and accompanied by 
advanced general tuberculosis. 2. In advanced pernicious anemia 

(279) 



280 THE MIDDLE EAR. 

or albuminuria, and in cachectic diabetes. 3. It is usually con- 
traindicated in young children. 4. In all cases where the disease 
is confined to the ossicles and tympanic cavity. 5. In adults who 
have scanty otorrhea without odor, with improper opening of the 
drum membrane, behind which are retained masses of secretion. 
6. In all cases where it is possible to effect a cure by any of the 
other methods described. 

Technique of the Radical Mastoid Operation. — It was in 1873 
that von Troltsch made the first attempt to modify the Schwartze 
mastoid operation by removing portions of the posterosuperior 
canal wall. Later on both Schwartze and Korner described cases 
in which portions, at least, of the posterior canal wall were removed. 
Krister, in 1899, outlined in a more definite manner the impor- 
tance of the operation, and the various steps to be followed in 
performing it. About the same time von Bergmann defined the 
simultaneous opening of the mastoid, and the removal of the 
posterosuperior osseous canal wall of the external auditory canal, 
and designated the procedure the "radical mastoid operation." 
Stacke, in 1891, published a description of the operation which has 
since borne his name, by which the superior canal wall is removed 
by cutting from the tympanum toward the mastoid antrum. 
Furthermore, he was the first to suggest the formation of a suitable 
skin flap, fashioned from the membranous portion of the external 
auditory canal. 

Various operators have from time to time suggested minor 
modifications, both of the operation upon the bone and in the forma- 
tion of the meatal skin flap. 

The patient is prepared for the operation after the manner 
described for the simple mastoid operation (page 225), with the 
exception that, inasmuch as the posterior incision is usually closed 
at the primary operation, we advise the shaving of the least pos- 
sible amount of the patient's hair. (For a description of local 
anesthesia of the mastoid process see Chapter VIII, page 91, and 
Figs. 50, a and 180). In women, and especially those who are 
obliged to earn their own livelihood, the shaving of a considerable 
section of the scalp becomes a serious drawback. Furthermore, it 
is possible by following suggestions given in the chapter on "Acute 
Mastoiditis" (page 225) to operate successfully with but little sacri- 
fice of hair. 

The Incision. — The curvilinear incision is similar to that (Fig. 
133) employed for the simple mastoid operation, but in the radical 
operation it may be located closer to the attachment of the auricle. 
This is permissible because it rarely becomes necessary to remove 
extensive portions of the cortex over the posterior portions of the 
mastoid process. Moreover it is advisable because the resultant 
scar thus becomes considerably obscured in the fold which marks 
the line of attachment of the concha to the temporal bone. The 
anterior and posterior flaps, including the periosteum, are then 
rapidly separated from the bone forward and backward by means 
of the periosteal elevator (Fig. 134), until the cortex is completely 



THE RADICAL MASTOID OPERATION. 281 

exposed to view (Fig. 140). The anterior flap should be reflected 
further forward than in the simple mastoid operation, in order to 
expose the outer posterior margin of the osseous meatus to full 
view. 

Before proceeding with the operation upon the bone, we 
separate the posterior attachment of the fibrocartilaginous portion 
of the external auditory canal by sliding a small periosteal elevator 
(Fig. 135) into the postauricular wound, and inward along the 
posterior osseous canal wall until complete separation of the soft 
tissues is effected. This procedure usually separates the drum 
membrane from its normal attachment. The anterior lip of the 
wound, including the posterior membranous canal wall, is then 
retracted either by the employment of a Jansen retractor (Fig. 
190) or, following the method employed by most American otolo- 
gists, a strip of gauze is introduced into the posterior wound 
and drawn outward through the membranous canal (Fig. 191). 
In the former method the retractor is held by an assistant during 
the entire procedure, while, in the latter procedure, a loop is made 




Fig. 190. — Jansen's fibrocartilaginous wall retractor. 

of the gauze strips, which" is grasped by artery forceps, the latter 
being held in the hand of an assistant. At the same time the entire 
wound is firmly retracted, either with Allport's or Jansen's mastoid 
retractors (Fig. 140). Ordinary hand retractors may be employed 
for this purpose, but are less efficacious. 

We now proceed to excavate the mastoid antrum and cells 
after the manner followed in the simple mastoid operation (Figs. 
142, 145, 146 and 149). The majority of foreign operators and their 
followers remove the posterior osseous canal wall simultaneously 
with the excavation of the mastoid antrum and cells, while most 
American operators enter the mastoid antrum as a preliminary 
procedure. The preliminary mastoid operation, whereby the 
mastoid antrum is thoroughly exposed to view, reveals those ana- 
tomical landmarks which outline the external semicircular canal 
and the location of the facial nerve, thereby lessening the danger 
of injury to these bodies while the posterosuperior osseous canal 
wall is being removed. The additional time required in operating 
by this method is clearly in the interest of the patient, inasmuch 
as it^ minimizes the danger of injury to the facial nerve and 
labyrinth. 

The cortex is then removed throughout a sufficient area to 
enable the operator to fully determine the extent of the disease in 
the bone. The mastoid tip cells are exposed and every vestige of 
diseased bone is then removed from the mastoid process. 

The removal of the posterosuperior wall of the osseous canal 



282 



THE MIDDLE EAR. 



constitutes the next step in the operation (Fig. 189). This is 
accomplished by means of mallet and chisel or by the Kerrison 
chisel forceps. The author often removes the outer portion of the 
wall with a small pair of rongeur forceps, by introducing one jaw 
of the forceps into the mastoid wound, and the ether into the 
osseous external canal. The Kerrison chisel forceps, small size, 
are then employed to complete its removal. With proper caution, 




Fig. 191. — A completed tympanomastoid excavation, showing the 
removal of the ossicles and all the soft tissues from the tympanum, 
together with the remains of the annulus tympanicus, the cortex and cells 
of the mastoid, the posterosuperior osseous canal wall, the diseased zygo- 
matic cells, curetment of the tympanic orifice and the Eustachian tube, 
and the entire surface made smooth and free from rough or overhanging 
bone. 

it is unnecessary to employ the Stacke protector (Fig. 192) in the 
radical operation. The outer wall of the epitympanum (attic) is 
then removed, and mainly by means of the Kerrison forceps (Fig. 
189), but completed with small chisels and curets. The exploring 
probe should be introduced into the attic from time to time in 
order to guard against the removal of unnecessary portions of the 
overhanging squamous bone and possible exposure of the dura. 
Furthermore, during the removal of the outer attic wall the 



THE RADICAL MASTOID OPERATION. 283 

operator should guard against injury to its inner wall, which is in 
close relation with the facial nerve. The removal of the postero- 
superior osseous canal wall, together with the outer wall of the 
epitympanum, reveals the ossicles or such portions of these little 
bones as may remain, providing they have not already succumbed 
to the necrotic process. They are usually deeply imbedded and 
sometimes entirely obscured by granulations. 

One assistant should be assigned to the duty of wiping the 
blood from the operative field and to remove the chips of bone, in 
order that the important landmarks may not become obscured. 
At this stage of the operation, the bone cavity having now become 
exposed to view, the wound should be tightly packed with gauze 
which has been soaked in a 1 to 5000 solution of adrenalin, the 
packing to remain for one or two minutes. Upon removing the 
gauze, the entire wound is free from blood, and hence is visible 
throughout. 




The Stacke protector. 



The incus and malleus should then be carefully removed, but, 
unless the labyrinth is necrotic at some point, the stapes should 
remain undisturbed. Before proceeding further we carefully 
examine the entire area with the exploring probe, in order to deter- 
mine as far as possible the extent of the necrosis. 

Returning to the mastoid portion of the wound, this region 
should be freed from all overhanging bone and rough areas, and 
furthermore the entire surface should be made smooth by means 
of a sharp curet or electric burr. 

The completion of the operation calls for (1) a wide open com- 
munication between the mastoid region and the tympanic cavity 
proper. This is chiefly gained by lowering the posterior canal wall. 
With a small and very sharp chisel the bone in this region is 
gradually chipped away. At the floor of the aditus the bone should 
be removed as near as possible to the Fallopian canal, without 
exposure of the facial nerve at any point ; meantime sufficient bone 
should be left to protect the oval window from injury. The 
removal of the overhanging portions of the squamous portion will 
also materially enlarge this space. The Richards curet (Fig. 193) 
is well adapted for this purpose. 1 Having completed this impor- 
tant step of the operation, the operator's attention is again given 
to the tympanic cavity, from which every remaining vestige of 
mucous membrane, granulation tissue and necrosed bone should 
be curetted. A most important procedure, and one upon which 
the final success of the operation often depends, is the removal 
of diseased areas in and about the tympanic orifice of the Eusta- 

i See Fig. 192a. 



284 THE MIDDLE EAR. 

chian lube. By removing the mucous membrane from about and 
within the tubal orifice, it is hoped to replace the membrane so 
removed with granulations which eventually will close off the 
communication of the Eustachian tube with the midde-ear spaces, 
and thus prevent further infection from the nasopharynx. It is 
common to discover diseased bone cells ranged about the tubal 
orifice, and sometimes these extend a short distance into the tube, 
especially in its upper wall. All such diseased areas of bone should 
be thoroughly removed. The Eustachian orifice curet devised by 
Neumann (Fig. 194) is well adapted for curetting the Eustachian 
orifice, and enables the operator to cut away a considerable portion 



Fig. 193.— The Richards curet/ 

of its lining membrane. The opposite end of the Neumann curet 
has a file construction suitable for smoothing the denuded bone 
within the tubal orifice. 

The above-described technique is generally practised by 
American otologists in effecting the removal of the diseased areas 
in and about the Eustachian orifice. The results are not invariably 
favorable, but are in the main satisfactory. Upon the subject of 
closure of the Eustachian tube, Gerber 1 remarks, there is as yet 
no satisfactory means at hand which gives absolute results. He 
believes that epidermis transplantation over this orifice is to date 
the best procedure. With this statement the author cannot agree, 
unless it is to be understood that the transplantation of epidermis 



Fig. 194. — Eustachian curet. (Neumann.) 

is to be preceded by thorough curettage of the tympanic orifice of 
the tube, and, even then, skin transplantation is of doubtful benefit. 
Heine's suggestion, namely, to leave a portion of the membrana 
tympani in situ, and place this by means of tampons over the orifice, 
seldom succeeds. Moreover paraffin injections into the tubal orifice 
have not met with success. 

The next step in" the operation consists of enlarging the 
external osseous canal, by cutting away a portion of its floor and 
anterior wall with the Richards curet ( Fig. 1 ( )3) or the electric burr, 
bearing in mind here, as well as in each step of the operation upon 
the bone, the precautionary measures hereafter enumerated. The 
operation upon the bone having now been completed (Fig. 101), 
the denuded area is thoroughly washed with a normal salt or boric 
acid solution, thus removing from its surface all blood-clots and 
residual debris. 



lArch. f. Ohrenhcilkundc, Bd. 70, Heft 3 and 4. 




Fig. 192a. — Allport and a few other American otologists strongly ad- 
vocate the use of the steel burr for excavating the interior of the bone 
cavity in the radical mastoid operation, claiming it to be "the best, quickest, 
and safest instrument for cleaning out the interior of the bone." The 
procedure has not been generally adopted as yet by the otologists of New 
York, whose work the author is familiar with. 



The radical mastoid operation. 285 

The Dangers and Accidents Attending the Radical Mastoid 
Operation. 

Precautions. — The intimate relation existing between the 
tympanic cavity proper, the epitympanum (attic), the mastoid 
arltrum, the mastoid cells, the facial nerve, the labyrinth, the 
jugular bulb;, the internal carotid artery, the sigmoid sinus and the 
meninges, even when normally located, emphasizes the possible 
danger of accident attending the radical mastoid operation through- 
out its entire course. 

In detail, the dangers and accidents which may be encountered 
during or subsequent to the performance of the radical mastoid 
operation are as follows : — 

(a) Injury to the trunk of the facial nerve. 

(b) Exposure and injury to the dura. 

(f) Wounding of the lateral sinus. 

(d) Accidental dislodgment of the stapes from its position in 
the pelvis of the oval window. 

(e) Injury to the labyrinth. 

(/) Injury to the jugular bulb through dehiscences in the floor 
of the osseous external meatus. 

(g) Injury to the external carotid artery through dehiscences 
in the floor of the tympanic extremity of the Eustachian tube. 

(h) Injury to the glenoid fossa. 

(a) Injury to the Trunk of the Facial Nerve. — Injury to the 
facial nerve occurs either from the careless manipulation of the 
-chisel, curet or rongeur forceps during the excavation of the bone 
while performing the radical mastoid operation, or because of 
dehiscences or defects in its bony covering which have resulted 
from necrosis. 

In extensive necrosis of the temporal bone the nerve trunk is 
prone to become exposed at some point, and this is so especially 
along the floor or the inner wall of the aditus ad antrum. When 
thus exposed, unless great care is exercised, the nerve trunk may be 
severely injured or completely severed during the operation. 
Furthermore, the nerve may be injured at any point in its course 
in the Fallopian canal, and, when the excavation of the cells 
and necrosed bone at the mastoid tip requires the exposure of the 
digastric muscle, there is considerable danger of injuring the facial 
nerve at its exit 'from the Fallopian canal. The latter form of 
injury is more liable to occur while operating upon infants and 
young children. Effusion into the Fallopian canal and undue 
pressure upon an exposed facial nerve by instruments or packing 
are less serious, nevertheless they are usually of sufficient severity 
to induce temporary paralysis of the muscles supplied by this nerve. 
Anomalies in the course of the facial nerve (Fig. 195) in rare 
instances are accountable for operation injuries. 

Facial paralysis cither temporary or permanent is the deplor- 
able result of injury to the facial nerve. The paralysis is temporary 



286 



THE MIDDLE EAR. 



when caused by an injury which docs not sever or otherwise 
destroy the nerve trunk, when resulting from pressure upon an 
exposed section of the nerve, or when due to inflammatory effusion 
into the Fallopian canal. 

Permanent facial paralysis occurs in cases where the nerve 
trunk has been severed, when a segment has been cut away, or when 
destroyed at some point by the purulent inflammatory process. In 
the latter class of cases the facial paralysis is complete, its advent 
is sudden and sometimes apparent before the patient has completely 
recovered from the anesthetic. 




Fig. 195. — Anomalous position of the facial nerve ; see key plate. 
(Specimen loaned by Dr. T. P. Berens.) 



In case the injury to the facial nerve is slight, the resultant 
paralysis is rarely complete, it develops gradually and often it does 
not appear until some days subsequent to the operation. 

It is not an uncommon occurrence for facial paralysis of otitic- 
origin to appear in patients upon whom no operation has been per- 
formed, in which event its advent is considered to be of serious 
import, especially when accompanied by labyrinthine symptoms, or 
when due to the encroachment of tumors. The extent of the 
paralysis of the facial muscles is ascertained by requesting the 
patient to smile (Fig. 196), to close the eyes (Fig. 197) or to 
whistle. 

Cases have been recorded where facial paralysis has disap- 
peared after long periods, even when the nerve trunk has been com- 
pletely severed, and in a few instances where the nerve has not 



THE RADICAL MASTOID OPERATION. 



287 



only been severed, but with more or less destruction to the tissue 
(Bezold and Pierce). Pierce records one case in which a quarter- 
inch section of nerve trunk was destroyed, causing complete facial 
paralysis, which finally was restored after a period of nine months. 
The prognosis, therefore, so far as it relates to the restoration of 
function, depends upon the nature, severity and extent of the 
injury which the nerve trunk has received. If due to temporary 
pressure upon the nerve trunk, to traumatism without destruction 
of tissue, or to inflammatory effusion into its sheath, a cure may be 




Key plate to Fig- 195. — A. Bristle passed through foramen ovale and 
semicircular canal. B, Attic. C, External auditory canal. D, Posterior 
wall of canal chiseled away to expose the nerve. This represents the usual 
bone wound of the posterior wall resulting from the usual Schwartze- 
Stacke operation. E, Facial nerve. F, Pin stuck into the sulcus that rep- 
resents the normal orifice of the stylomastoid foramen. 



expected. Notwithstanding the experiences above recorded facial 
paralysis, occurring as a result of complete destruction of the nerve 
trunk at any point, is almost invariably permanent. 

Facial paralysis of otitic origin should not be confused with 
that known as Hell's paralysis, which is not due to pyogenic invasion 
of the middle-ear spaces. 

For a description of the treatment of facial paralysis, the reader 
is referred to page 309. 

(b) Exposure and Injury to the Dura. (r) Exposure and 
Injury to the Lateral Sinus. — Exposure of the cerebral dura cover- 
ing the temporosphcnoidal lobe, or the cerebellar dura over the 



288 



THE MIDDLE EAR. 



sigmoid sinus or elsewhere, may occur during a mastoid operation, 
either by accident or of necessity. 

It occurs by accident when it results because of an anomalous 
position of the tissues involved, or as a result of chiseling or curet- 
ting beyond the recognized limits of the operative field. It results 
from necessity when the necrotic process in the bone has already 
destroyed the inner (visceral) cranial table at some point. 

Mere exposure of the surfaces of these organs is rarely if ever 
attended by serious symptoms or results, but the wounding of 
these tissues by infected instruments may result in serious intra- 
cranial infection. 




Fig. 196. — Complete facial paralysis. The patient was suffering from 
Bell's paralysis, and in the photograph was attempting to smile. 



Accidental puncture of the wall of the lateral sinus requires 
special mention because of the violent hemorrhage which follows. 
Unless controlled immediately the loss of blood produces serious 
shock to the patient. The hemorrhage is easily controlled by the 
introduction of small gauze plugs between the overlying bone and 
the proximal portion of the wounded sinus (Fig. 254). This acci- 
dent should by no means deter the operator from completing the 
operation. 

The hemorrhage does not usually recur at the time of the first 
dressing of the wound, but plugs of gauze should be at hand to be 
introduced in case it does. 

((/) Accidental Dislodgment of the Stapes. — The precautions 
heretofore recommended for avoiding injury to the facial nerve, 
while chiseling the posterior portion of the osseous external canal, 
hold good in preventing injury to the oval window and stapes. 






THE RADICAL MASTOID OPERATION. 



289 



Furthermore, during the curetment of the soft tissues of the tym- 
panic cavity, the operator should avoid the oval window. It is 
feasible to remove coarse, flabby, overhanging granulations about 
the oval window, but it should be accomplished without molesting 
the stapes. Dislodgment of the stapes opens the labyrinth to infec- 
tion and infective labyrinthitis may result. Moreover serious 
impairment in the hearing function becomes inevitable. 

(e) Injury to the Labyrinth. — Injury to the labyrinth at any 
point opens up its interior to infection, with all the train of deplor- 
able results which follow labyrinthine suppuration (Chapter 
XXIII). This accident should never occur to the experienced 
operator. 




Fig. 197.— Same patient. Taken while attempting to close the eyes. 

(/) Injury to the Jugular Bulb. — On account of its location 
underneath the floor of the osseous external meatus (Fig. 2) the 
jugular bulb is liable to injury when dehiscences in the bone at this 
point are present. Such dehiscences are not common, but occa- 
sionally are discovered during the operation. Wounding of the 
bulb is followed by a severe hemorrhage, which is easily con- 
trolled by tight packing. Eventual recovery may be expected 
unless septic thrombi intervene, in which event the case should be 
treated in the manner described for lateral sinus-thrombosis 
(Chapter XXIV). 

(g) Injury to the Carotid Artery Through Dehiscences in the 
Floor and Anterior Wall of the Tympanic Extremity of the Eusta- 
chian Tube. — Hemorrhage at this point usually occurs as a result 
of the wounding of the plexus of veins which surround the carotid 

19 



290 THE MIDDLE EAR. 

artery, and hence is easily controllable. A slight injury to the 
outer layer of the wall of the artery is not followed by severe 
hemorrhage, and simple packing with sterile gauze is sufficient to 
control the bleeding and protect the injured tissue from infection. 
Alarming hemorrhage follows when the wall of the artery is punc- 
tured, and the internal carotid should be ligated without delay. 

(// ) Injury to the Glenoid Fossa. — Injury to the glenoid fossa 
from careless chiseling occasionally occurs. Unless the capsular 
ligament is torn, no serious results are likely to follow. 

The avoidance of the above-described accidents and dangers is 
of the utmost importance, on account of the complications which 
are thereby prevented. There are certain essential preliminaries 
which should be mastered by all otologists, before attempting a 
surgical procedure which is attended by the possibilities of so many 
serious accidents and deplorable complications as surround the 
radical mastoid operation. He should not attempt these surgical 
procedures without first acquiring an intimate knowledge of the 
anatomy of the temporal bone and the adjacent structures. He 
should not only possess a knowledge of the operation per sc, but 
of all the complications which are liable to occur in connection 
therewith. His operations upon the living should be preceded by 
the acquirement of technical knowledge and skill gained from 
making numerous sections of the temporal bone, and by the per- 
formance of many operations upon the cadaver under competent 
instruction. Moreover he should further improve his technical 
knowledge, by witnessing the operations of experienced aural 
surgeons. 

Among the minor though essential precautionary measures, 
the following may be enumerated as requirements : — 

1. A sufficiently long primary incision to permit the necessary 
exposure of the cortex. 

2. Bright illumination of the wound cavity, thus enabling the 
operator to keep in view not only the landmarks, but also to dis- 
cover dehiscences of bone, anomalies of anatomy and the ravages 
of the necrotic process. 

3. The control of hemorrhage, and the speedy removal of all 
chips of bone from the wound cavity. 

The latter should be delegated to a trained assistant. 

Many of the above-enumerated accidents may be averted by 
the frequent employment of the exploratory probe throughout the 
entire operation. 

Plastic Surgery of the Fibrocartilaginous External 
Auditory Meatus. 

Having completed the required tympanomastoid excavation, 
the fibrocartilaginous meatus now claims attention, for from it 
skin flaps are to be constructed by means of plastic surgery, to be 
anchored upon the denuded surface of bone in a manner that will 
best promote rapid dermatization of the whole cavity. 



THE RADICAL MASTOID OPERATION. 



291 



The purposes of the meatal skin flaps are threefold: 1. To 
circumvent subsequent atresia of the external auditory canal. The 
incisions required in the formation of the skin flaps, herein- 
after described, serve at the same time to widen the fibrocartilagin- 
ous meatus sufficiently to prevent atresia of the external auditory 
canal, which might otherwise occur as a result of the loosening of 
the fibrocartilaginous attachment from the posterosuperior osseous 
canal wall during the operation upon the bone. 2. To amplify the 
external meatus to correspond with the increased size of the bone 
cavity within. The plastic operation allows a liberal opening for 
the introduction of dressings and for inspection of the cavity, and 
permits the proper aeration of the enlarged bone cavity with its 
large area of dermal lining, but the outer orifice should be sym- 




Fig. 198. — The Stacke meatal flap. 



metrical in contour and free from serious deformity of the auricle. 
3. The flaps are constructed and anchored upon the denuded bone 
surfaces in a manner that will most advantageously permit the 
desired rapid dermatization of the entire cavity. 

From the foregoing it will be seen that the construction and 
adaptation of a suitable skin flap from the fibrocartilaginous meatus 
is an essential procedure in all radical mastoid operations. The 
portion which is available for the purpose of covering the denuded 
bone cavity is necessarily limited to the posterior half, and even 
portions of this area are often absent because of sloughing which 
has resulted from prolonged suppuration and invasion of the 
underlying bone. Since Stacke first suggested the advisability and 
importance of dividing the fibrocartilaginous meatus into flaps 
as a step in the radical mastoid operation, numerous ingenious 
modifications have been made from time to time, a number of 
which procedures bear the names of the distinguished aurists who 
designed them. 

The aural surgeon should be familiar with all plastic pro- 
cedures, inasmuch as in individual cases one form of meatal flap 



292 



THE MIDDLE EAR. 



may excel another. The more important plastic flap operations 
are described as follows : — 

(a) The Stacke Flap. — Stacke was the first to suggest the 
construction of a plastic flap from the fibrocartilaginous canal. His 
flap, slightly modified by Jansen, is shown in Fig. 198. The 
concha is grasped by the left hand of the operator and turned 
forward sufficiently to fully expose the anterior portion of the post- 
auricular wound cavity. The narrow scalpel is then made to 
transfix the concha in exactly the opposite direction to that shown 
in the cut (Fig. 201), and the primary incision is then completed in 
the manner shown by the line a, b (Fig. 198), care meanwhile being 
exercised not to injure the anterior canal wall with the knifepoint. 

The second incision, c, d, commences at a point near the upper 




Fig. 199.— The Panze meatal flap. 



extremity of the first, and by being extended at right angles to 
the former it transfixes the fibrocartilaginous canal throughout its 
longitudinal axis. These incisions result in the formation of a 
narrow upper and a wider lower flap which when thinned out by 
removing the cartilage and superfluous soft tissues are turned 
respectively upward and downward and either sutured or tamponed 
into position. 

(b) The Panze Flap. — Panze modified the Stacke procedure 
above described by changing the situation of the second incision. 
In the Panze procedure the second incision commences at the 
middle point of the primary incision and is carried directly back- 
ward, transfixing the posterior wall of the fibrocartilaginous canal 
in its median line (Fig. 199). The latter incision is made either 
with scalpel or slender scissors, preferably the latter. When 
employing scissors for this purpose the blades are introduced after 
the manner shown in the illustration (Fig. 199). The lines of 
incision in the Panze flap form a T, and they result in the con- 
struction of two quadrangular flaps of varying dimensions. When 



THE RADICAL MASTOID OPERATION. 293 

the fibrocartilaginous canal is large and the primary incision is 
carried well outward into the flaring portion of the meatal orifice, 
the flaps thus constructed are comparatively large. After being 
freed of all cartilage and superfluous soft tissues the flaps are 
turned, one upward and the other downward and adjusted to the 
denuded walls of the bone cavity. The entire cavity is then firmly 
reinforced with gauze which is introduced through the enlarged 
meatal orifice, with the result that the wounded area within is 
protected and at the same time the flaps are held in place. Many 
operators prefer to suture the flaps (Fig. 203). 

The merits of the Panze flap are summed up as follows: It is 
not difficult to construct ; it insures a wide-open external meatal 
orifice, and it is especially adapted to children. 




Fig. 200. — The dotted line indicates the location of the primary incision 
to be followed in constructing the Stacke, the Panze and other modifi- 
cations of the Stacke skin-flap. 

A- further modification of the Stacke flap, one which for 
several years has been employed by the author in suitable cases, 
was recently described by Whiting 2 as an "abundant meatal flap." 
Jansen also has recommended a similar procedure. In its construc- 
tion a primary semicircular incision is made to transfix the auricle 
along the meatoconchal junction (Fig. 200), carrying the incision 
a sufficient distance into the concha to materially amplify the 
meatal orifice, and at the same time to afford a large area of skin 
for transplantation. Upon the reverse side the primary incision 
is made to sever the posterior attachment of the fibrocartilaginous 
canal from its conchal attachment (Fig. 201 K Upon completion 
of the primary incision the scalpel is withdrawn and reintroduced 
from the postauricnlar side of the wound. The final incision is 
then extended in a backward direction, at right angles to the 



The Laryngoscope, August, 1909. 



294 



THE MIDDLE EAR. 



primary, throughout the entire length of the canal, as near its floor 
as possible (Fig. 202). The Map thus formed is oblong and of 
considerable dimensions. Its posterior surface should now be 
denuded of redundant cartilage and soft tissues, after which it may 
be grasped by suitable forceps and swung upward and backward 
and thus made to cover a considerable area of the posterosuperior 
portion of the osseous wound cavity. 

The flap may be anchored either by means of a stitch uniting 
its edge to that of the fascia or periosteum above (Fig. 203) and 
further held in contact with the surface of denuded bone by tampon- 




Fig. 201. — A posterior view of the primary incision. (Diagrammatic.) 



ing with gauze packing introduced through the enlarged meatal 
orifice. 

The Korner Flap. — The Korner flap differs materially in form 
from all others, inasmuch as by means of two parallel incisions the 
posterior half cf the fibrocartilaginous meatus is separated from 
the anterior, the incisions being extended from the tympanic end 
outward to and slightly beyond the meatal border of the concha. 
The incisions, according to Korner, should be from 10 to 12 mm. 
apart. The completed incisions release a somewhat oblong or 
tongue-shaped flap from the fibrocartilaginous canal with its base 
of attachment at the concha (Fig. 204). 

The incisions are followed by free hemorrhage from small 
vessels, often requiring ligatures or torsion. 

Before placing the flap in position it should be drawn forward 
through the aperture in the canal, and thence outward into the 
external meatal orifice, where, under ample illumination, it is 



THE RADICAL MASTOID OPERATION. 



295 



divested of superfluous soft tissue and cartilage. The flap which is 
now composed of integument only is returned to the posterior 
wound space to be anchored in its proper place upon the denuded 
bone. 

In the author's judgment the Korner flap never should be 
sutured because it can more advantageously be spread upon the 
denuded bone when no sutures are employed. 




Fig. 202. — The final incision in the modified Stacke meatal flap. 
(Diagrammatic.) 

After the postauricular wound has been closed the operator, by 
introducing an aural speculum of large size, under bright illumina- 
tion, is, enabled to grasp the flap with a slender pair of thumb 
forceps and locate it in the bone cavity to the best advantage. 
Furthermore, before withdrawing the speculum the initial gauze 
packing should properly be adjusted. 

Viewed from the plastic standpoint, the advantage of the Korner 
flap lies in the fact that it occupies a rather central position upon 
the denuded bone, where from its borders spring epithelium which 
extends in all directions to meet the outgrowth from the more 
remote intecrument. 



296 



THE MIDDLE EAR 



The Siebenmann Flap. — In the Siebenmann modification the 
primary incision is made to extend through the middle posterior portion 
of the fibrocartilaginous canal from its tympanic end following the 
line of the second incision in the Panze procedure, except that 
before invading the conchal extremity of the canal it is met by two 
short converging incisions which extend well outward beyond the 
conchomeatal juncture. As completed, the incisions result in a 
Y-shaped aperture, which furnishes three meatal flaps, two of 
which are oblong and made up of the posterior canal wall, the third 
being a short triangular flap constructed largely from the tissue of 
the concha. 




Fig. 203. — The meatal skin-flap stitched to the temporal fascia above. 
(Diagrammatic.) 



Neumann has suggested a modification in the construction of the 
Siebenmann flap which is a distinct improvement. The modification 
consists in shortening the primary incision in the posterior canal 
wall, and is made up as follows : The auricle is grasped in the 
operator's left hand and lifted directly outward in order that the 
slender scalpel may be introduced through the outer meatal orifice 
to the full depth of the fibrocartilaginous canal. The incision is 
then carried from the tympanic extremity of the fibrocartilaginous 
canal forward through the centre line of the posterior wall through- 
out about two-thirds of its length (Fig. 205). The knife is then 
withdrawn and the operator's index finger is introduced into the 
outer meatal orifice. Retaining the finger in its position and by 
means of scissors two final incisions are made to diverge in 
the direction indicated by the dotted lines (Fig. 205), one in an 



THE RADICAL MASTOID OPERATION. 



297 



upward direction through the conchal orifice at the upper border 
of the meatus, and a similar one to the lower. Both should be 
extended a sufficient distance into the concha to permit the operator's 
finger to pass freely through the outer meatal opening (Fig. 206). The 
three flaps should now be divested of redundant soft tissue and cartilage 
and the V-shaped conchal flap anchored to the fleshy portion of the 
anterior lip of the mastoid wound (Fig. 207) and the upper and lower 
flaps adjusted to the denuded bony area in the wound. These may be 
retained in position by suitably adjusted sutures or gauze packing. The 
improved flap thus described offers a considerable distribution of 
integumental covering for the osseous wound cavity, and at the same 
time the cosmetic results are highly satisfactory and free from serious 
deformity. 




Fig. 204. — The Korner meatal skin-flap. (Diagrammatic.) 



The Ballance Flap. — The technique to be followed in con- 
structing the flap designed by Ballance differs somewhat from the 
forms heretofore described. The line of incision to be followed is 
depicted in Fig. 208, and is often referred to as the shepherd's crook 
incision. Ballance lays stress upon the importance of removing all 
redundant muscular and fibrous tissue from the posterior surface of 
the fibrocartilaginous canal and from the adjoining portions of the 
concha lying in the immediate vicinity as a preliminary measure, 
after which the incision is made in the form shown in the illus- 
tration. 

With slender-bladed scissors or scalpel the incision is carried 
through the median portion of the posterior canal wall to within a short 
distance of the attachment to the concha. From tins point a semi- 
circular incision is made downward, outward and upward into the tissue 
of the concha. The circular portion together with the upper half of 
the entire canal wall is then drawn in an upward direction and anchored 
to the muscular or fibrous tissues of the external wound by means of 



298 



THE MIDDLE EAR. 



stitches. The construction of the Ballance flap is attended with con- 
siderable difficulty, much of which may be obviated by making the lat- 
ter or curved portion of the incision with the knife introduced from the 
anterior surface of the auricle. 

Precautionary Measures. — It should be the invariable rule in 
all radical mastoid operations which are uncomplicated to construct the 
plastic skin-flap from the fibrocartilaginous canal wall and to close 
the posterior wound, as the final step. In case any considerable 
portion of the dural covering of the brain or the lateral sinus 
becomes exposed during the operation upon the bone, the closure 




Fig. 205. — The primary incision in the construction of the Neumann 
modification of the Sieben'mann meatal flap. 

of the postauricular wound and the construction of the plastic flap 
should be delayed until all danger of complications has passed, a 
period ranging from eight to fifteen days. 

All incisions into the cartilage of the auricle in connection with 
the construction of the skin-flaps should be clean cut and under strict 
asepsis, in order to avoid subsequent perichondritis. A few cases of 
perichondritis from this source have been reported wherein extensive 
and prolonged infiltration and suppuration ensued, and all terminated 
in extensive and deplorable external deformity. 



Thiersch's Skin Grafts. 

The extensive excavation of bone required by the radical mastoid 
operation leaves a considerable area of denuded bone surface. A por- 
tion of this surface we cover with the plastic flaps constructed from 



THE RADICAL MASTOID OPERATION. 299 

the fibrocartilaginous canal wall, in the manner heretofore described. 
The dermatization of the remainder of the wound may be accomplished 
either by the gradual outgrowth of epithelium from the borders of the 
plastic flaps or by the transplantation of Thiersch's skin grafts. 

Authorities are divided in opinion as to the results to be obtained 
from the transplantation of Thiersch's grafts into the radical mastoid 
wound cavity. The author believes that the average results obtained 
from carefully constructed plastic meatal flaps, when anchored in the 
most favorable location within the wound cavity, are fully equal to 
those obtained by the employment of skin grafts. It is true that 
occasionally brilliant results follow the successful transplantation of 
Thiersch's grafts, but, unfortunately, the proportion of such successes 
is inconsiderable. 




Fig. 206. — Completing the incision for the Neumann modification of 
the Siebenmann meatal flap with scissors. The position of the operator's 
finger in the external meatus is indicated by the dotted line. 

Technique. — A section of the patient's arm or thigh, preferably 
the latter, should be surgically prepared for the removal of epidermis 
by being scrubbed and protected by a sterile bichlorid of mercury 
dressing. 

A large razor, one surface of which is flat (Fig. 200), is most 
adaptable for the purpose of removing the epidermal graft. The razor 
should be dipped in warm normal saline solution and the surface of 
skin made flat and tense by the surgeon's hand drawing in one 
direction, and the hand of an assistant making similar traction in 
the opposite. Placing: the edge of the razor upon the skin it is made 
to penetrate the epidermal layer. The blade is then laid flat upon 
the surface of the patient's skin and made, 1,Y a series of lateral 
sawing motions, to sever a section of epidermis of sufficient size to 
line the denuded bone cavity. By dropping warm saline solution 



300 



THE MIDDLE EAR. 



upon the razor while cutting the epidermal graft, the latter is kept 
lloating and hence the edges do not curl. 

The Ballance set of instruments, having been sterilized, are then 
employed for the purpose of transplanting the graft. By teasing the 
graft from the razor to the surface of the spatula ( the size to be 
gauged by the dimensions of the graft), it becomes comparatively a 
simple process now to introduce it into the wound, where by employing 
the teasing probe it is gradually spread upon the denuded bone, there to 
be pressed securely and firmly in position. 

The spreading of the graft usually requires considerable manipula- 
tion. Should blood accumulate underneath the graft it should be 
sucked out with a small glass pipette. In the same manner the accumu- 
lation of air bubbles mav be removed. 




Fig. 207. — The Neumann modified flap completed. The V-shaped 
central flap is stitched to the soft tissues of the anterior lip of the post- 
auricular wound. (Diagrammatic.) 



The grafts are maintained in position by means of sterile gauze 
packing, which must be carefully introduced. Unless symptoms 
arise which necessitate an examination of the wound cavity, the 
primary dressings should be allowed to remain undisturbed for 
from five to eight days. Aural surgeons are not in accord in regard 
to the most favorable time for introducing a Thiersch skin graft 
into the osseous mastoid wound. 

Dench favors applying the graft at the primary operation. Bal- 
lance delays it for ten days. It seems incredible to expect an epithelial 
graft, when applied to a freshly denuded surface of bone, to "take." 
Nevertheless, according to Dench and others, such grafts do sometimes 
"take" seemingly without the intervention of granulations. It is prob- 
able that after an interval of eight to ten days from the primary opera- 
tion 'the conditions are more favorable for skin grafting. It is both 
possible and feasible to introduce skin grafts through the enlarged 
external auditory meatus, into the wound cavity. 



THE RADICAL MASTOID OPERATION. 



301 



Closure of the Postauricular Meatal Wound. 

Contrary to the rule followed in the simple mastoid operation, 
wherein the postauricular wound cavity is permitted to remain open 
and to heal by granulation from the bottom, in the radical mastoid 
operation, on account of the wide open drainage of all the middle-ear 
spaces into the external meatus, made possible by the extensive 




Fif 



208. — The Ballance meatal skin-flap. 



removal of bone, the postauricular wound, with few exceptions, may 
advantageously be closed at the primary operation. The exceptions 
to this rule are described above under the heading "Precautionary 
Measures." 

When the wound edges approximate without tension, ordinary 
catgut or silkworm gut sutures may be employed in closing the post- 




Fig. 209. — A razor, with one flat surface, which is especially applicahle 
for removing Thiersch's skin grafts. 



auricular wound. Unfortunately, however, the approximation of 
the wound edges requires considerable tension, especially in patients 
who have submitted to previous simple or radical operations, and in 
whom much scar tissue is intermingled in (lie tissues about the former 
mastoid incisions. Hence some form of traction sutures should lie 
employed for suturing this class of wounds in order to insure primary 
healing. To this end the so-called mattress suture (Fig. 210) has 



302 



THE MIDDLE EAR. 



been advocated by J. J. Thomson of the author's staff in the ear 
service of the Manhattan Eye, Ear and Throat Hospital. The 
mattress suture accomplishes the double purpose of producing 

traction upon the lips of the wound, and, by causing the wound 





Fig. 210. — The mattress suture 
employed for closure of the post- 
auricular mastoid wound. 



Fig. 211. — A mastoid wound 
closed by mattress sutures and re- 
inforced by interrupted sutures. 



edges to protrude, a considerable area of the underlying denuded 
soft tissues upon either side are also brought into apposition, thus 
enhancing the probability of final healing throughout the wound. 

Three mattress sutures, when re-enforced by a few interrupted 
sutures (Fig. 211), usually suffice to effectually close a postauricular 
mastoid wound. 




Tin- Michel metal clamp suture outfit. 



The same purpose is accomplished by employing the Michel metal 
clamp sutures (Fig. 212). When properly adjusted the metal clamp 
sutures succeed in producing considerable protrusion of the lips of 
the wound, and hence a wider area for final union is obtained (Fig. 
213). 



THE RADICAL MASTOID OPERATION. 



303 



After having sutured the postauricular wound it is advisable to 
readjust the gauze packing. Hence, the primary packing of gauze is 
withdrawn through the enlarged meatal orifice. Under bright illumina- 
tion the surgeon should then wipe away all blood-clots from the bone 
cavity, readjust the meatal skin-flaps if necessary, and repack the 
wound in its entirety. As a final step outer dressings and a retaining 
bandage should be applied, after the manner advised for dressing the 
simple mastoid wound (Figs. 156 and 157). The outer dressings 
may be discarded upon the healing of the postauricular wound and 
the removal of the stitches. 





Fig. 213. — The technique of ap- 
plying the Michel clamp suture to 
the postauricular mastoid wound. 



Fig. 214.— The first step in the 
closure of a postauricular fistula. 
The dark line A indicates the line 
of incision. (Passow-Trautmann 
method. ) 



Closure of Persistent Postauricular Openings. 

Various plastic operative procedures have been devised for closing 
postauricular fistulous openings which communicate with the 
middle-ear spaces. 

The Passow-Trautmann Method. — The steps of the operation 
are as follows : — 

(a) A circular incision penetrating to the bone posteriorly and to 
the perichondrium anteriorly is extended around the outer marginal 
border of the fistulous opening (Fig. 214). 

(b) The skin included within the incised area, including the 
periosteum, is then freelv released from the bone and the margins are 
inverted sufficiently to bring the opposing free borders together with 
the dermal layer facing the middle-ear space. 



304 



THE MIDDLE EAR. 



(c) The opposing edges are then united by catgut sutures. Fol- 
lowing the advice of Trautmann the periosteal flap is closed by four 
sutures, two threads being inserted into each side ( Fig. 215). 

( </ ) Finally, the edges of the outer circle of the wound are freely 
elevated, then approximated and closed either with interrupted sutures 
or the Michel meatal clamp sutures (Fig. 216). 

The Mosetig-Moorhof Method. — The Mosetig-Moorhof plastic 
flap is adaptable to the closure of small postauricular fistulous open- 
ings. The steps of the operation are: — 

(a) A U-shaped skin-flap is formed, similar to but larger in out- 
line than the mouth of the fistula, and with its base or hinge at the 




Fig. 215. — The second step in 
the Passow-Trautmann operation 
for closure of a postauricular fis- 
tula. The sutures A, B, and C, D, 
in the posterior lip of periosteal 
flap are to he united to the corre- 
sponding sutures upon the oppo- 
site side. 




Fig. 216. — The first row of 
sutures have been tied, the knots 
being still visible. The outer row 
of sutures,— one tied, one ready to 
tie, and two remain untied. 



periphery of the fistulous opening (Fig. 217). This flap may be 
formed from behind or above the fistulous opening if necessary. 

(b) An incision is then extended around the rim of the post- 
auricular opening, except at the point which marks the pedicle of the 
skin-flap (Fig. 218). The outer edges of this incision are freely 
elevated from the bone. 

(c) The oval or U-shaped skin-flap is then turned upward and 
laid over the fistulous opening with the dermal surface facing the 
middle-ear spaces. The edges are then approximated to the freshly 
denuded and loosened rim of the fistulous opening and retained in place 
with sutures (Fig. 219). 

(d) Finally the skin wound from which the flap has been formed 
is closed by sutures (Fig. 220). 



THE RADICAL MASTOID OPERATION. 



305 



The Results of the Radical Mastoid Operation. 

The results obtained by the complete radical mastoid operation, 
assuming that the treatment, both operative and postoperative, is up 
to the recognized standards, are favorable as a whole, but are 
influenced by the kind and nature of the pathological findings. 

For instance, in tuberculous and syphilitic necrosis the results are 
less favorable than would otherwise be obtained, on account of the 
-underlying constitutional dyscrasia. 

At the Eastern Section Meeting of the American Laryngological, 
Rhinological and Otological Society, held in Philadelphia on January 





Fig. 217. — The incision shows Fig. 218. — The second incision 
the U-shaped skin-flap cut from which releases the skin around the 
the inferior margin of the post- border of the postauricular open- 
auricular opening. (Mosetig- ing. (Mosetig-Moorhof method.) 
Moorhof method.) 

9, 1909, the author reported the results on the otorrhea, hearing 
and life from 123 radical mastoid operations as follows : — 

The cases here reported do not cover any definite period of time, 
but are selected as a series which may fairly well represent the results 
of the complete operation. 

In some instances the records are incomplete for certain of the 
results : — 

1. The results on otorrhea. 

2. The results on hearing. 

3. The results on life. 

On the otorrhea the results are recorded in 103 of the 123 cases. 

Of the 103 recorded results there were 84 cures, and in 18 the 
discharge either persisted, became intermittent, or appeared in con- 
nection with occasional exfoliations of epidermis or cholesteatoma. 

On the hearing the results are recorded in 75 out of the 125 cases. 

Of these 75 cases the hearing was improved in 28, it was 
unchanged in 25. and it was impaired in 22. 

On life out of 123 cases there were 7 deaths from complicating 
lesions. In none of the fatal cases save 4 did the operation hasten 



306 



THE MIDDLE EAR. 



the fatal issue, and in nearly all the radical procedure was but an 
incident in operating for the relief of complicating lesions, sinus- 
thrombosis, brain abscesses, and meningitis. 

In one case, hereinafter reported (page 377), I discovered at the 
time of the radical operation, a large abscess of the temporosphenoidal 
lobe, which never had given localizing symptoms or interfered with 
the usual duties of the patient. 

Five of the 6 cases included in this list are of recent date, and 
the results are still uncertain. 

On the Otorrhea. — The purulent discharge is cured whenever 
healthy dermatization of the entire cavity is complete. This is not 
possible in every case, inasmuch as in a limited proportion of cases 
the surgeon has to contend with impaired general health, con- 




Fig. 219.— The third step. The 
skin-flap is turned upward and 
laid on the fistulous opening, 
where it is retained by sutures. 
(Mosetig-Moorhof method.) 




Fig. 220. — The final step in the 
Mosetig-Moorhof operation, con- 
sisting of the closure of the skin 
wound from which the skin-flap 
was constructed. 



stitutional dyscrasias, and deep-seated disease of the more remote 
areas of the ear, especially the Eustachian tube. 

Even though a slight postoperative discharge persists, the 
operation accomplishes the removal of large areas of the necrosed 
bone and granulations, and opens up the entire field to inspection 
and local treatment. Any remaining discharge is usually without 
danger to the patient's life. 

On Life. — Inasmuch as this operation upon the temporal bone 
serves to eradicate an infective necrotic process from an area which 
is in close proximity to the cerebrum, cerebellum, lateral sinus, 
labyrinth and facial nerve, it becomes, when timely performed, a 
life-saving measure. Clinical experience furnishes abundant proof 
of this assertion. 

On Hearing. — The operation never is performed in the interests 
of the hearing function, and a statement to that effect should be 
made to the patient before operating. Nevertheless, the hearing 
results are of much interest and importance. Providing the laby- 



THE RADICAL MASTOID OPERATION. 307 

rinth is intact and no inflammatory adhesions exist, the hearing 
either remains the same or is improved by the operation. It is 
made worse in but a very small percentage of cases. 

Finally, regarding the effect upon the hearing function, the 
operation accomplishes the removal of adventitious tissue of a 
dangerous type from the temporal bone and middle ear, and 
converts the membranous linings into epithelium free from necrotic 
foci. 

The results herein enumerated do not materially differ from 
those reported by Griinert, Trautmann, Grossman, Stacke, Dench 
and others. 

In the above remarks I have referred only to the complete 
radical operation. Attempts have been made from time to time, 
first by Korner, and later by Heath, in England, and Bryant and 
Ballenger, in America, to modify the operation by leaving the 
ossicles and membrana tympani intact, in the hope of bettering the 
hearing results. They are all incomplete operations, inasmuch as 
the annular ring, the outer wall of the attic and the ossicles, three of 
the chief centres of necrosis in this disease, are necessarily left 
untouched. The author is extremely skeptical regarding favorable 
results from any incomplete operation in cases of extensive necrosis 
of the tympanic wall, ossicles, aditus, and mastoid antrum. 

The Postoperative Treatment of the Radical Mastoid Operation. 

Proper after-treatment of the radical mastoid wound is essential 
to the final success of the operation — in fact, the surgeon must possess 
the same measure of knowledge and skill in the technique of the post- 
operative treatment of the wound as for the operation itself, inasmuch 
as many failures are directly due to careless or unskillful after-treat- 
ment. Therefore, no surgeon should undertake the management of a 
case. requiring the radical operation unless either he or a competent 
substitute is prepared to bestow the required time and skill until final 
healing has taken place. The period covered by the after-treatment 
varies from one to three months. The primary gauze packing in the 
operative cavity under usual circumstances should not be changed until 
about the seventh day. The external dressings should be renewed 
daily and the postauricular wound inspected until the latter is healed, 
which is usually from five to six days. The object of the daily change 
of outer dressings is to discover stitch infections and to keep the wound 
dry. As soon as firm union has taken place the sutures should promptly 
be removed, and snould any single suture become infected its early 
removal is advised. The outer dressings may be discarded as soon as 
the postauricular incision is healed. 

Gare must be exercised in removing the primary packing from the 
osseous wound cavity in order not to disturb or displace the meatal 
flaps or give the patient unnecessary pain. Some difference of opinion 
exists as to the pressure with which the gauze should be packed into 
the cavity after the first few dressings. Two general views obtain at 
the present time. There are those who prefer very tight packing and 



308 



THE MIDDLE EAR. 



those who do not tampon the cavity at all, each claiming good results. 
Between these extreme views all grades of pressure have their advo- 
cates. Formerly, it was the opinion of the majority of authorities that 
tight packing was essential for the control of the granulations and to 
hasten epidermization. Better results have been obtained by the 
author when the middle-ear spaces have been snugly packed at each 
dressing, inasmuch as he has thereby been enabled to prevent the 
osseous wound cavity from becoming completely filled with granula- 
tions. 

The posterior or mastoid portion of the cavity should be very 
lightly packed, thus allowing granulations to fill the deeper areas. By 
so doing the surface requiring dermatization is proportionately lessened 
and without detriment. The granulations must be carefully watched 
and not allowed to become exuberant and flabby, inasmuch as granula- 
tions of this type offer a serious barrier to the line of epidermatization 




H- 



Fig. 221. — The methods of suturing to be followed in the end-to-end 
anastomosis of nerve trunks. (Schematic.) 

that should extend in all directions from the flap margins. Excessive 
secretions, by bathing the granulating surfaces, render them soft and 
flabby and macerate the epithelial surfaces. On this account the cavity 
should be kept as dry as possible, daily dressings frequently being 
necessary for this purpose. In some instances it may become necessary 
to apply caustics to exuberant granulations. Silver nitrate or ortho- 
chlorophenol applications are effective in subduing excessive granula- 
tions. It very rarely becomes necessary to stimulate the granulations, 
but if so balsam of Peru aplied to the sluggish areas, or the substitution 
of iodoform gauze for the plain gauze packing, usually produces the 
desired results. In stubborn cases the author obtains excellent results, 
both in subduing unhealthy granulations and in promoting epidermiza- 
tion, by packing the granular surfaces with tampons covered with a 
20 per cent, scarlet-red ointment. 

With the diminution of the secretion the surface of the cavity 
should be covered with boric acid powder or aristol, or a mixture of 
these, before replacing the tampon. Under the most favorablecircum- 
stances six to eight weeks usually elapse before epidermization is 
complete, and a much longer time is often necessary, but the tampons 
are rarely of service after the third or fourth week. 



THE RADICAL MASTOID OPERATION. 309 

The Medicinal, Mechanical and Surgical Treatment of Facial 
Paralysis of Otitic Origin. 

Medicinal. — Drugs are of but little avail in the treatment of 
this type of facial paralysis. Such remedial measures as tend to stimu- 
late the digestive functions and correct faulty nutrition should be 
employed. For this purpose the moderate use of salines and the 
internal administration of iron and strychnia or the iodin compounds 
are recommended. Meanwhile, advantage should be taken of all 
opportunities for improved hygiene and nutritious diet. Mechanical 
massage of the paralyzed muscles and the employment of the faradic 
current have long been advocated as remedial measures in cases of 
injury without destruction of the nerve trunk. These measures may 





Fig. 222. — Schematic illustration of the lateral implantation method of 
anastomosis of nerves. 

hasten the recovery of function, and, even when the nerve trunk has 
been severed, aid in preventing muscular atrophy during the period in 
which the hope of final recovery may be entertained. An individual of 
ordinary intelligence may be taught both to apply massage and the 
interrupted current to his own face. 

Surgical Treatment. — Attempts have been made, and appar- 
ently with some degree of success, to restore the function of the nerve 
by grafting the distal end of the severed facial nerve into the trunk of 
either the hypoglossal or spinal accessory nerve of the corresponding 
side, preferably the hypoglossal. The splicing of nerves after this 
manner produces an interchange of function ; hence the functional dis- 
turbance will be less noticeable when the facial nerve is spliced to the 
hypoglossal than when joined to the spinal accessory. Taylor, Frazier 
and others have reported successful cases, especially when the opera- 
tion of anastomosis has not been too long delayed. Knowing that 
restoration of function, in many cases of injury to the facial nerve, 
occurs even after a considerable lapse of time, it becomes somewhat 
difficult to decide upon the exact time when the anastomosis operation 
should be performed. Positive knowledge that the nerve trunk has 



310 



THE MIDDLE EAR. 



been completely destroyed throughout a considerable portion of its 
course warrants immediate resort to operative procedures. 

There are two general methods of uniting nerve trunks for the 
purpose of anastomosis: (a) by end-to-end anastomosis; (fr) by 
lateral implantation. 

(a ) End-to-end Anastomosis. — Of the two methods, that known 
as end-to-end anastomosis is simpler in technique and therefore requires 
less surgical skill, but it possesses the disadvantage that it requires com- 
plete severing of the healthy nerve, which invariably is followed by 
paralysis of the muscles which it supplies. 



MASTOID PROCESS. 
(TIP CUTAWAY) 




FACIAL NERVE 



HYPOGLOSSAL NERVE 

(dotted portion underneath 

TISSUE* 



Fig. 223. — Schematic illustration of the dissection for the anastomosis 
of the facial nerve with the hypoglossal nerve. 



Inasmuch as equally good results are obtained by following the 
second (lateral implantation) method, and without permanent loss of 
muscular power, the end-to-end method is now rarely employed. If 
end-to-end anastomosis of the facial nerve is desired, it should be 
united with the hypoglossal nerve, both nerves being exposed in 
the manner hereinafter described for lateral implantation. 

The paralyzed segment of the facial nerve is dissected from a 
point slightly within the mastoid tip, where it is joined to the central 
segment of the severed hypoglossal nerve (Fig. 221). 

(b) Lateral Implantation. — The favored method of lateral 
implantation is accomplished by implanting or grafting the paralyzed 
segment of the facial nerve into the body of the hypoglossal nerve 
through a longitudinal slit (Fig. 222). 



THE RADICAL MASTOID OPERATION. 311 

The Technique of Faciohypoglossal Anastomosis. — An incision 
is made along the anterior border of the sternocleidomastoid muscle, 
from its attachment to the tip of the mastoid process to the end of 
the cricoid cartilage. After dividing the skin, superficial fascia, and 
platysma myoides, by separating the lips of the wound the sterno- 
cleidomastoid muscle is revealed. This muscle is then retracted 
posteriorly and the parotid gland is exposed and turned forward. 
The deep fascia is then freely incised and retracted, thus revealing 
the posterior belly of the digastric muscle. This muscle, together 
with the occipital artery at its junction with the carotid artery, 
serves to guide the operator to the hypoglossal nerve. The nerve is 
sought at this point by means of a blunt dissector. When found it 
should gently be raised from its bed and drawn forward to a 
convenient site for the anastomosis procedure. 

Since Duel and Frazier 
advocated the removal of a 
small section of the mastoid 
tip for the purpose of secur- 
ing a longer portion of the 
nerve trunk, this point rather 
than its point of entry into 
the parotid gland is favored 
for locating the facial nerve. 

In his later operations 
Taylor has adopted this 
method and considers it to 
be the quickest and surest 

method of securing a suffi- 

, , £l <■ ,i . 1 r r\&. ZM. — Schematic representation 

Cient length of the trunk of of the anastomosis of the severed end 
the facial nerve for anasto- of the facia] nerve with the hypoglossal 
mosis. The facial nerve trunk nerve by lateral implantation. 
is then gently raised from its 

bed and severed as high .up as possible in the Fallopian canal (Fig. 
223). The distal section of the nerve is then turned downward. A 
small portion of the sheath of its proximal end should then be removed, 
in order that its axis cylinders, when grafted into hypoglossal, may 
come into direct contact with those of the latter nerve. 

A longitudinal slit is then made into the sheath of the hypoglossal 
nerve, into which the proximal stump of the facial nerve is inserted, 
care being exercised to ingratiate its fibres into the fibres composing 
the hypoglossal nerve trunk, but directed toward its proximal end. 
The grafted end of the facial nerve is then anchored into its position 
by means of fine-silk sutures, introduced by small, round, curved needles 
(Fig. 224). ' Taylor contends that wrapping the junction of the two 
nerves with Cargile membrane tends "to prevent the ingrowth of con- 
nective tissue into the field of the anastomosis." 

The deep tissues are then as nearly as possible replaced into normal 
position and the external wound united by sutures. The postoperative 
treatment consists in the continual inn of the medicinal and mechanical 
measures advocated in foregoing paragraphs, to the end that "return- 
ing nerve power may find good muscle to work on." (Taylor.) 




CHAPTER XXIII. 
COMPLICATING LESIONS OF PURULENT OTITIS MEDIA. 



PURULENT LABYRINTHITIS. 
SECTION I— INTRODUCTORY. 

(a) Explanatory Note. — Before considering in detail the ques- 
tion of labyrinthine suppuration, Section I of the present chapter 
describes the experimental methods devised for investigating the 
irritability of the vestibular apparatus. The information presented 
is in the main the elaboration of notes of the lectures delivered by 
Neumann, of Vienna, during his visit (1910) to America. 1 

In the rotation tests he describes the two horizontal canals as 
acting simultaneously and, when the head is flexed either forward 
or backward, the two superior canals as acting simultaneously. 
The posterior canals are ignored on the ground that, although they 
may be excited by rotation with the head down on either shoulder, 
we are unable to determine from which ampulla the centre is 
stimulated, as both are occupying the same relative position. 

He further affirms that excitation of a centre from a horizontal 
canal produces horizontal nystagmus, and from a superior canal 
rotatory nystagmus. 

This is evidently faulty from the anatomical standpoint, as it 
has been demonstrated that the plane of the superior canal on one 
side corresponds to the plane of the posterior canal on the other, 
and vice versa. It would therefore seem to follow that the rotatory 
nystagmus produced by turning with the head bent forward or 
backward is the resultant of the action of a superior and posterior 
canal, and not the effect of stimulation or inhibition through a single 
superior canal. 

Nevertheless the information is submitted for the reason that 
it offers a practical and useful method of arriving at a definite 
conclusion with regard to the irritability or non-irritability of the 
vestibular apparatus. 

(b) Symptoms Referable to Interference with the Function of 
the Vestibular Apparatus. — There are three principal symptoms 
directly referable to interference with the function of the vestibular 
apparatus. They are: 1, vertigo; 2, nystagmus; 3, disturbances of 
equilibrium. 

It should be noted that these symptoms are in the first place 
due to irritation of the vestibular apparatus on the diseased side, 
and that the direction of the nystagmus, the apparent motion of 
surrounding objects, and the direction in which the patient tends 



1 The author is indchted to his colleague, Dr. John B. Rae, for extending 
his notes of these lectures to form Section I of this chapter. 

(312) 



PURULENT LABYRINTHITIS. 313 

to fall can be determined as being the result of stimulation of the 
centre on that side. Later, mainly within a very short period of 
time in acute diffuse cases, the spontaneous nystagmus and the 
disturbances of equilibrium are found to be the result of stimula- 
tion of the centre on the sound side. This is not, however, a real 
stimulation of that centre, but is rather to be explained on the 
ground that, the end organs of the vestibular nerve on the diseased 
side having been destroyed and no stimuli therefore reaching that 
centre, the centre on the sound side overbalances the other, and the 
later nystagmus and disturbances of equilibrium result. These 
symptoms rapidly disappear as the centres accommodate themselves 
to altered conditions, and will not be observed at all unless the 
patient is seen at an early stage of labyrinthine involvement. 

The diagnosis of destruction of the labyrinth is therefore 
usually to be made on the induced rather than on the spontaneous 
symptoms. 

Vertigo. — Vertigo is the subjective sensation which a patient 
experiences when one or other Of the tracts governing equilibrium 
is suddenly disturbed. These tracts are three in number: 1, the 
vestibulo-ocular ; 2, the vestibulo-spinal ; 3, the vestibulo-central. 

The vestibulo-ocular tract is connected through Deiters's nucleus 
and the fasciculus longus with the corpora quadrigemina and the 
ocular muscles. 

The vestibulo-spinal tract connects with the cord and has to 
do with the maintenance of muscle tone necessary for equilibrium. 

The vestibulo-central tract connects with the higher centres 
in the cerebellum. 

Destruction of any one of these tracts will result in vertigo 
and disturbances of equilibrium. By training, the remaining two 
tracts will accustom themselves to altered conditions and equilibrium 
will be restored. 

In tabes, the vestibulo-spinal tract being interfered with, 
equilibrium is maintained and orientation is possible by co-opera- 
tion of the vestibulo-ocular and the vestibulo-cerebellar tracts. On 
closing the eyes, the vestibulo-ocular tract being also eliminated, 
exact orientation is impossible and disturbances of equilibrium 
result. 

The commonly experienced tendency to fall on looking from 
an unaccustomed height is explained by disturbance of the vestib-. 
ulo-ocular and vestibulo-spinal tracts. 

The so-called "digestion vertigos" are the result of autoin- 
toxications, the erring tract in such cases being the vestibulo- 
central. 

In cases exhibiting spontaneous vestibular vertigo and nystagmus, 
the apparent motion of surrounding objects and the direction in which 
the patient tends to fall follow certain definite laws which can best 
be remembered with relation to the nystagmus. 

The rule is that surrounding objects apparently move in 
the direction of the quick component of the nystagmus, and the 
patient tends to fall in a direction opposite to that of the quick 



314 THE MIDDLE EAR. 

component of the nystagmus. This direction of falling can be altered 
by changing the position of the patient's head. 

For example: If the patient have nystagmus to the left — that is, 
the quick component of the nystagmus motion is to the left — he will 
tend to fall to the right. If now the patient's chin be turned toward the 
left shoulder, he will tend to fall forward, and, if the chin be turned 
toward the right shoulder, he will tend to fall backward. 

This change of the direction of falling is characteristic of disturb- 
ances of equilibrium of direct vestibular origin, and in this manner such 
disturbances of equilibrium can be differentiated from those due to 
other causes. 

The tendency for the body to fall following vestibular stimulation 
has a counterpart in the deviation of the extremities. Both the tend- 
ency to fall and the deviation of the extremities occur in the plane or 
the planes of those semi-circular canals in which the stimulation is 
aroused. The phenomenon of falling and deviation are known as the 
reaction movements. 

In addition to the nystagmus, vertigo, nausea and vomiting we 
formerly believed that the so-called reaction movements followed 
stimulation of the labyrinthine end organs as a reflex. Because of the 
uniformity of the nystagmus the direction of the reaction movements 
was expressed in terms of the former; thus we said that the reaction 
movements of the body and of the extremities were always in the 
direction of the slow component of the nystagmus. 

It was understood that there was no direct connection between the 
nystagmus and the reaction movements. From more recent work on 
the physiology of the labyrinth it appears that our conception of the 
reaction movements as a reflex originating in the cerebellum, and influ- 
enced by the cerebrum, is erroneous. The reaction movements are the 
objective expression of the vertigo and in all probability are cerebral 
in origin. 

The vertigo of vestibular origin is frequently associated with 
nausea and vomiting. 

Nystagmus. — Nystagmus may be defined as oscillation of the eye- 
ball. It varies in degree and may be easy or difficult of detection. It 
may be elicited in any position of the eye, or only in extreme abduction, 
according to the amount present. It is a reflex, and is in origin ves- 
tibular, ocular or central. 

Ocular nystagmus is undulatory and is to be observed in any posi- 
tion of the eye. The excursion of the globe in one direction is eqtial to 
that in the other, both as regards extent and. rapidity. Vestibular nys- 
tagmus is rhythmic and consists of two components — a slow vestibular 
component, and a rapid cortical movement in the opposite direction. 
The nystagmus is named from the direction of the quick component, 
and not from the slow vestibular component as might be expected. 

The eyeball is in equilibrium when the impulses from the vestibulo- 
ocular apparatus on both sides are exactly balanced by the impulses 
from the cortical apparatus. Nystagmus results when one center in the 
vestibulo-ocular apparatus does not balance the other. When great in 
amount vestibular nystagmus can be observed in any position of the 



PURULENT LABYRINTHITIS. 315 

eye, but when small in amount it can only be elicited in extreme abduc- 
tion in the direction of the quick component. In a certain proportion 
of normal cases a small amount of nystagmus can be obtained on ex- 
treme abduction to the right and to the left. This is equal in amount on 
both sides, and is physiological. 

(c) Induced or Experimental Evidence of Labyrinthine In- 
volvement. — It should be clearly understood that the tests to be briefly 
described below are employed to distinguish between an irritable or 
functionating vestibular apparatus and a non-irritable or destroyed 
labyrinth. 

In dealing with these experimental tests there are certain funda- 
mental laws which must clearly be borne in mind before the tests can 
rightly be applied and correct deductions from their results made. 

Ewald's Experiment. — It will be enough to state that Ewald 
demonstrated that the endolymph movements in the different canals, 
either in the direction of the utricle or toward the non-ampullated ends, 
resulted in definite movements of the head, with corresponding eye 
movements. 

His method wa*s to open a canal and by a suitable plug to occlude 
completely the membranous portion. At a position nearer the ampulla 
a second opening was made through, the bony wall of the canal and a 
small piston introduced. This piston was in communication with a 
bulb, so that by compression or aspiration the endolymph could be 
moved at will, either toward or away from the ampulla. 

Hoegye's Law. — Hoegye demonstrated that, when the centre of 
one side was stimulated from the vestibular apparatus, the adductor 
ocular muscles on the same side, and the abductor muscles on the oppo- 
site side contracted, resulting in a slow conjugate movement of the eyes 
in a direction away from the stimulated centre. Thus, stimulation of the 
right centre brings about a slow movement to the left and vice versa. 

This is a very important law, and it should be noted, remembering 
that nystagmus is named from the quick cortical movement, opposite in 
direction to the slow vestibular component, that nystagmus to the right 
is the result of stimulation of the right centre, and nystagmus to the 
left, the result of stimulation of the left centre. If now to these two 
fundamental laws be added the results of endolymph movements in 
different directions in the different canals, we shall have data from 
which to draw deductions when the experimental tests are applied. 

Movement of the endolymph in a given canal is either toward or 
away from the utricle. The moving endolymph will change the direc- 
tion of the ampullary cilia, which will either be directed toward the 
utricle or toward the non-ampullated end of the canal. Tn the case of 
the horizontal canal, movement of the cilia in the direction of the utricle 
will result in stimulation of the vestibular centre on that side, while 
movement of the cilia toward the non-ampullated end will result in 
inhibition of that centre. 

With the superior canal, conditions are exactly opposite. Ciliary 
movement toward the non-ampullated end will give rise to stimulation 
of the centre on the same side, while ciliary movement toward the 
utricle will determine inhibition. 



316 



THE MIDDLE EAR. 



It is here again repeated that our knowledge of this intricate sub- 
ject is as yet so restricted that these laws are submitted, only at their 
true value as offering a fairly reliable working method toward deter- 
mining the condition of the vestibular apparatus. 

Briefly to recapitulate, it should be borne in mind that, in the hori- 
zontal canal, movement of the cndolymph and cilia toward the utricle 

stimulates the center on the same 
side. In the case of the superior 
canal that movement of the cn- 
dolymph and cilia toward the 
non-ampuUated end stimulates 
the centre on the same side, and 
that stimulation of a centre 
brings about contraction of the 
adductor ocular muscles on the 
same side and of the abductor 
ocular muscles on the opposite 
side. 

Experimental Tests. — 
The methods by which the ves- 
tibular apparatus may be experi- 
mentally stimulated are four in 
number and are known as the 
Rotation, Caloric, Fistula and 
Galvanic tests. The first three 
depend for their recognition 
upon the ciliary movements, and 
the laws described above must 
be applied in estimating their 
results. 

Rotation Tests. — If a ves- 
sel containing water be rotated 
on an axis at right angles to the 
sur|ace of the fluid, the water is 
at first left behind, gradually ac- 
quires the speed of the rotating 
container and, on rotation be- 
ing suddenly stopped, continues 
moving in the direction of the 
rotation. This is the principle 
applied in the rotation tests. It 
will therefore be observed that 
the first effect of rotation will be 
that the endolymph in the canals 
affected will be left behind, and the ampullarv cilia will have their 
direction altered accordingly. Nystagmus will result but will not be 
noted on account of the continuance of rotation. When rotation ceases 




Fig. 225. — Author's rotator for con- 
ducting the rotation tests for nystagmus. 
It has a broad seat, high arms and an 
elevation of 23 inches, which permits 
the proper observance of the symptoms. 
The base is solid; hence is unaffected 
by the rotation movement. Further- 
more, it is supplied with a strap to pre- 
vent the patient from falling during the 
rotation. 



PURULENT LABYRINTHITIS. 



317 



and the endolymph continues in motion, the direction of the cilia 
will again be altered, and nystagmus will again result. This can 
be observed, and it is this so-called "after-nystagmus" alone which 
proves of value in our observations. 

It is evideni. that the primary nystagmus will always be in the 
direction opposite to that of the after-nystagmus. It is also evident 
that those canals alone will be affected by rotation whose planes are 
at right angles to the axis of rotation. 

If, then, a patient is seated in a suitable revolving chair (Fig. 
225), head erect, and is rotated to the right ten times, the hori- 
zontal canals, whose planes are now at right angles to the axis 
of rotation, will be affected. On rotation ceasing, the endolymph 



^STASMUSjTOj Le 




Fig. 226. 



in the left canal will have a motion in the direction of the utricle, 
while that in the right canal will have a motion in the direction of 
the non-ampullated end. If we now apply our laws, we reason that 
the left centre is stimulated while the right centre is inhibited. 
The left centre being stimulated, Hoegye's law reminds us that 
the adductor muscles of the left eye and the abductors of the right 
contract, giving rise to a slow, vestibular movement to the right. 
This is corrected by a quick cortical movement in the opposite 
direction, and the repetition of these movements results in a pro- 
longed nystagmus to the left. This is diagrammaticallv represented 
in Fig. 226. 

It will be noted that the two canals, for diagrammatic purposes, 
are joined together, so that the drawing shows both ampullated 
ends, the non-ampullated ends being united. The arrows in the 
ampulla; indicate the direction of the cilia after rotation. The left 
centre being stimulated, the red lines show the adductor muscles 
of the same side and the abductors of the opposite side in con- 
traction. 



318 



THE MIDDLE EAR. 



Rotation of the patient to the left will produce a nystagmus 
to the right of equal duration. This can be diagrammatically 
expressed in a manner similar to that for rotation to the right. 

The plane of the superior canals may be brought at right angles 
to the axis of rotation by bending the head of the patient either 
forward or backward, at' an angle of 90°. The result of rotation 
can be reasoned out as before. Thus, with the head bent forward, 
the united superior canals can diagrammatically be represented as a 
semicircle with the ampullated ends opening backward. If the 
patient be now rotated ten times to the right and stopped, the after- 
flow of the endolvmph will carry the cilia on the left side in the 
direction of the non-ampullated end, and on the right side toward 



t ,ySTA 6M" S TQ ^ 





Fig. 227. 



Fig. 228. 



the utricle. Applying the rule, we find the left centre to be stimu- 
lated and the right centre to be inhibited. 

Following Hoegye's law, we will have slow vestibular move- 
ments of the eyes to the right, with quick cortical corrections to the 
left, resulting in a prolonged rotatory nystagmus to the left. This 
is diagrammatically represented in Fig. 227. 

Rotation to the left with the head bent forward will in a 
similar manner give a prolonged rotatory nystagmus to the right. 

With the head bent backward, the united superior canals form 
a semicircle open in front. After rotation to the right in this posi- 
tion, the ampullarv cilia on the left side will be directed toward the 
utricle, and those on the right toward the non-ampullated end. 
Again applying the rule, we find the right centre to be stimulated 
and the left inhibited. There accordingly ensues a series of slow 
vestibular movements of the eyes to the left, with quick cortical 
corrections to the right? resulting in a prolonged rotatory nystagmus 
to the right. This is diagrammatically represented in Fig. 228. 



PURULENT LABYRINTHITIS. 



319 



Rotation to the left with the head backward will give a pro- 
longed rotatory nystagmus to the left and can be reasoned out and 
represented as before. 

Before applying these tests the patient should be examined for 
physiological nystagmus, and taught to follow the movements of 
the finger in front of the eye. 

Immediately after turning, the upper lid of the eye on the side 
of the expected nystagmus should be elevated, and reflected light 
from a head-mirror thrown on the globe. The duration of .the 
nystagmus from the cessation of turning until the disappearance of 
the nystagmus should be carefully noted for each direction of rota- 
tion. Just after rotation the nystagmus will be evident in all posi- 

■SLOW M OVEMEN T 
RIGHT 




Fig. 229. 

tions of the eye, but, as the intensity diminishes, the eye should be 
abducted in the direction of the quick component, 

As a rule it will be sufficient to test for rotation reactions with 
the head erect. But, inasmuch as the horizontal canals are most 
frequently employed in our everyday movements, they may be diffi- 
cult of excitation, and a comparison of the results of rotation to 
right and left may be unsatisfactory and undecisive. In such a case 
one of the other positions must be resorted to, and, while both are 
disagreeable to the patient, that with the head bent forward is less 
so, and is therefore to be selected in preference to the other. 

Before considering the difference in the duration of the after- 
nystagmus when one vestibular apparatus is not functionating, the 
following diagram is inserted to show how the duration of nystag- 
mus may be expressed in terms of quantity. In this diagram the 
normal tonus of each centre is represented by the numeral 5, and the 
amount of stimulation or inhibition reaching the centre from the 
peripheral apparatus by the numeral 15. 

Let the patient be rotated to the right, head erect (Fig. 229). 



320 THE MIDDLE EAR. 

Before rotation the two centres balance each other with a 
normal tonus of 5. 

After rotation, the left centre receives an added stimulus of 15, 
so that it is now raised to the value of 20. 

The right centre is inhibited to the extent of 15, so that its 
value is now equal to zero. 

Left centre before rotation = 5 
Right centre before rotation = 5 
Left centre after rotation = 20 
Right centre after rotation = 

The balance between the centres is very evidently disturbed in 
favor of the left and there must result a prolonged nystagmus to 
the left. 

nystagmus To 




Fig. 230. 

With the quantitative method understood it is comparatively 
a simple matter to reason out what must happen when one vestib- 
ular apparatus is not functionating, and the patient is submitted 
to rotation to right and left with head erect or bent forward or 
backward. 

The two following diagrams will be sufficient to show how this 
is done. We will suppose the right labyrinth to be destroyed and 
the patient rotated first to the right and then to the left with the 
head bent backward, at 90°, thus bringing the plane of the superior 
canals at right angles to the axis of rotation. 

Rotation of patient to the right, head bent backward, right 
vestibular apparatus destroyed (Fig. 230). 

Before rotation right centre = 5 
Before rotation left centre =5 



PURULENT LABYRINTHITIS. 321 

After rotation the right centre remains as before, no stimulus 
reaching it from the destroyed vestibular apparatus, . '. = 5. 

After rotation left centre is completely inhibited, . '. = 0. 

The balance between the centres is disturbed but only to a 
small extent, with the result that we expect a short rotatory nystag- 
mus to the right. 

Rotation of patient to the left, head bent backward, right 
vestibular apparatus destroyed (Fig. 231). 

Before rotation the right centre = 5 

Before rotation the left centre = S 

After rotation the right centre remains unaffected = 5 

Left centre receives added stimulus of 15 and therefore equals 5 + 15 = 20 




Fig. 231. 



The balance between the centres is again disturbed, but now 
to a marked degree, resulting in a prolonged rotatory nystagmus to 
the left. 

It will now be understood that even with one vestibular appara- 
tus completely destroyed there will be nystagmus on rotation in 
both directions. As previously stated, nystagmus to the right is 
from overbalance of the right centre, and nystagmus to the left 
from overbalance of the left centre. But a glance at the first of 
these two diagrams will show that the overbalance of the right 
centre is not due to added stimulus of that centre but to complete 
inhibition of the other. Hence it follows that, whatever be the 
position of the head, the patient must be rotated to the right, the 
duration of the nystagmus noted, and then rotated to the left and 
a similar observation made. Our deduction is to be made from a 
comparison of these two figures. There is considerable room for 
error, because our methods are not mathematically exact and due 
allowance for this must be made. If the duration of nystagmus on 

21 



322 THE MIDDLE EAR. 

one side is half the duration of the other, it is not safe to conclude 
that the vestibular apparatus on the side of the shorter duration 
is destroyed. Other tests must be employed. But, if the duration 
of nystagmus on one side is one-third or less than one-third that of 
the other, it is strong presumptive evidence of the destruction of 
one vestibular apparatus. 

To take a concrete example : Suppose that after rotation to 
the right in the erect position a patient exhibits nystagmus to the 
left for thirty-five seconds and after rotation to the left he exhibits 
nystagmus to the right for eight seconds. 

It is evident that the same amount of stimulation is not reach- 
ing each centre from its corresponding vestibular apparatus on 
rotation, and, remembering that nystagmus to the right is the 
result of stimulation of the right centre, it is easy to conclude that 
the right vestibular apparatus is not functionating. 

Caloric Reactions. — The caloric reactions are due to endolymph 
movements as are the rotation reactions, but are obtained by the appli- 
cation of heat or cold to the outer labyrinthine wall. It is a well- 
known physical law that, if heat be applied to a vessel containing 
fluid, a current in the fluid will be set up in a direction upward from 
the point of application of the heat. Conversely, if cold be applied, 
the current in the fluid will be in a downward direction. If we 
consider the canal system as a vessel containing fluid and direct a 
stream of water above the body temperature through the external 
meatus against the outer labyrinthine wall, there will result a 
slight movement of the endolymph vertically upward in all the 
canals. But it is evident that only in that particular canal -whose 
ampulla occupies a vertical direction — that is, whose long axis is at 
right angles in a vertical direction to the stream of hot water, will 
there be a corresponding change of direction of the ampullary cilia. 
Thus, with the head erect, injection of hot or cold water will alter 
the direction of the cilia in the superior canal alone. With the head 
bent forward or backward at an angle of 90° the change of direc- 
tion of cilia will occur in the horizontal canal. 

If we remember Hoegye's law, and also the rule that, in the 
external semicircular canal, movement of the cilia toward the 
utricle causes stimulation, and that, in the superior canal, movement 
in the direction of the non-ampullated end causes stimulation, we 
are ready to reason out the results of the application of heat or cold 
in the different positions of the head. 

The following diagram illustrates the effect of syringing the 
right ear with water above the temperature of the endolymph, the 
head being erect (Fig. 232) : — 

It will be noted that after sufficient irrigation the cilia in the 
ampulla of the superior canal will have a direction toward the non- 
ampullated end. This is the direction of stimulation, and, accord- 
ingly, applying the law of Hoegye, there will result slow vestib- 
ular movements of the eyes to the left, each corrected by a quick 
cortical movement to the right — in short, there will be evident 
a nystagmus to the right. 



PURULENT LABYRINTHITIS. 



323 



If cold water be used the cilia will be directed toward the 
utricle. This being the position of inhibition, the left centre over- 
balances the right and there accordingly results a series of slow 
vestibular movements to the right with quick corrections to the 
left, or, in brief, nystagmus to the left. 

The following diagram illustrates the effect of syringing the 
left ear with cold water, the head being bent forward at an angle 
of 90°. We are now, therefore, dealing with the horizontal canal 
(Fig. 233):- 

After irrigation, the cilia will be directed toward the utricle, which 
is the position of stimulation. The left centre being the more active, 



frt yST A6HUS TO- tia^ 




b a 




B 



AMPULLA OF 
KT- SUP- CANAL, 

Fig. 232. 



I 



AMPULLA OF 
J\ LEFT HORIZONTAL 
CANAL 

Fig. 233. 



the slow vestibular movements are to the right, with the rapid cortical 
corrections to the left. There results nystagmus to the left. 

If hot water be used the after-position of the cilia will be toward 
the non-ampullated end. This being the position of inhibition the right 
centre becomes the more active, with a resulting nystagmus to the right. 

With the head bent backward at an angle of 90° the results can 
be reasoned out in a precisely similar manner. 

The caloric tests are applied to distinguish between a functionating 
and a non-functionating vestibular apparatus. Even with a functionat- 
ing apparatus they may fail because of our inability to raise or lower 
the temperature of the endolymph in the presence of polypi, excessive 
granulation or cholesteatomatous masses. Coagulation of the endo- 
lymph may also on certain occasions be the cause of failure of the 
caloric reactions. 

In applying the tests a graduated irrigator should be employed so 
that the exact amount of water necessary to begin the nystagmus may 
be accurately noted. The temperature of the water should also lie 
exactly determined by the use of a thermometer. The examiner should 
raise the upper lid of the eye and throw reflected light upon the globe. 



324 THE MIDDLE EAR. 

It is to be remembered that this test depends entirely upon the physical 
laws governing the application of heat or cold. The stream of fluid 
must be applied without force, and the height of the irrigator be such 
as to eliminate any suspicion of mechanical disturbance of intra- 
labyrinthine pressure. 

The cold-water test is intensely disagreeable to the patient who has 
a functionating vestibular apparatus and should be discontinued upon 
the first sensation of dizziness. 

As a general rule, water warmer than the body temperature will 
excite hot-water nystagmus and vice versa. It is therefore essential to 
know the body temperature at the time of making the tests. The tem- 
perature of the patient may be considerably over normal, and, should 
no provision be made 'for this, we may obtain the cold-water reaction 
when we are attempting to elicit the hot-water nystagmus. 

NO DISTURBANCE OF BALANCE; 
NO NYSTAGMUS 




AMPULLA OF ^ 
RT' SUP • CANAL J|| 

DESTROYED 2%I 

Fig. 234. 

It is also worthy of note that the local temperature of the endo- 
lymph may be above the body temperature in inflammatory conditions 
about the labyrinth, and due allowance must be made for this. 

Cold reactions can be obtained in normal cases with the water at a 
temperature of about 68° F. In inflammatory conditions, spoken of 
above, they may be elicited with water at a temperature of 86° F. 

It may become of the utmost import in the course of a radical 
operation to determine whether or not the vestibular apparatus is 
functionating. The caloric tests can be applied, but on account of the 
anesthesia there will be no cortical corrections. So that, instead of 
the usual nystagmus, we will only obtain a slow vestibular movement of 
the eyes, in the direction determined by the position of the head and 
ear involved. The eyes will remain in this position until the cilia 
resume their normal direction. 

The results of making caloric tests in all the examples which have 
been given have had reference to cases in which the vestibular appa- 
ratus has been functionating. Where the vestibular apparatus is not 
functionating, the result must be negative, as will readily be understood 



PURULENT LABYRINTHITIS. 325 

from the following diagram, in which hot-water irrigation is made 
in the right ear, presupposing destruction of the right labyrinth, 
head erect (Fig. 234). 

After irrigation, the vestibular nerve being destroyed, neither 
stimulation nor inhibition will affect the right centre. There will be no 
disturbance of balance of the centres, and no nystagmus. 

Fistula Test. — As its name implies, this test is only to be elicited 
in those cases in which there is a pathological opening in the outer wall 
of the labyrinth. When the reaction is obtained, it will be evidence 
not only of the presence of a fistula, but also of a functionating ves- 
tibular apparatus, and for that reason may very well be the first test 
used in chronic discharging cases with vestibular symptoms. As with 
the caloric reactions, this test may fail because of the presence of granu- 
lation or cholesteatomatous masses. 

The test is also known from the method of application as the 
compression and aspiration test. 

The results here, as in the rotation and caloric tests, are obtained 
by movements of the endolymph, and Hoegye's law and the other laws 
with reference to the positions of stimulation and inhibition also apply. 

Experience has shown that fistulse occur most commonly in the 
external horizontal canal because of its position on the floor of the 
aditus and exposure to carious processes. The next most common site 
of fistula is in the neighborhood of the oval window, after which the 
promontory is most likely to be involved. 

It would seem at first glance, when a fistula is present and the 
reaction can be obtained, that it would be a simple matter to determine 
from the ocular movement the exact position of the carious opening. 
But, when we consider that endolymph may be moved into all the 
ampullae when the breach in the outer labyrinthine wall is near the oval 
window, it will immediately be apparent that the question may become 
very complicated. Accordingly, in the light of our present knowledge, 
it is sufficient to say that, when compression brings about a certain 
movement of the eyeballs and when aspiration causes a movement in 
the opposite direction, we can make the diagnosis of a fistulous opening 
in the outer wall of the labyrinth. Should this opening, on operation, 
not be found in the horizontal canal, it should be sought for either 
about the oval window or on the promontory. 

Failure to obtain the reaction on compression and aspiration will 
not exclude the possible presence of a fistula. 

Method of Making the Test. — A Politzer bag is used with a piece 
of rubber tubing and an appropriate olive tip to fit snugly into the 
external meatus. To make compression the olive tip is placed cor- 
rectly in the ear and the bulb squeezed. To make aspiration the bag 
is first emptied of air, the olive tip fitted into the meatus and the bag 
allowed to expand. 

Fallacies. — It has already been mentioned" that the reaction may 
not be obtained even in the presence of a fistula when the opening is 
blocked bv granulations or a cholesteatoma. In certain subjects the 
entrance of cold air into the meatus may give rise to the symptoms of a 
cold-water reaction. This will not be difficult of differential diagnosis, 
as will be shown later, but should be borne in mind. 



326 THE MIDDLE EAR. 

When the Eustachian tube is wide open there may be such a rapid 
escape of air by this means that sufficient condensation is not allowed 
to produce the reaction. In adults the condition of the tube can be 
determined beforehand by the use of the catheter, and the employment 
of Valsalva's method at the time of practising compression should 
eliminate this source of error. 

Results of Compression and Aspiration. — When a fistula is present 
and accessible, and compression is made, a true nystagmus does not 
result. There is instead a slow conjugate deviation of both eyes in a 
direction depending upon the canal involved and the direction of the 
endolymph movement in that particular canal. The eyes will slowly 
resume the normal position. Upon aspiration there will be a slow 
conjugate deviation of the eyes in the opposite direction. Remember- 
ing what has been said above with regard to the limitations of the 



9TR0N6 SLOW MOVEMENT 




WEAK. SLOW MOVEMENT 




FISTULA 



FISTULA (fj 



I 



Fig. 235. Fig. 236. 

conclusions that can be drawn from the results of these tests, the fol- 
lowing diagram shows the theoretical effect of compression when a 
fistula is present in the left horizontal canal (Fig. 235) : — 

On compression the cilia will be directed toward the utricle, which 
in the horizontal canal is the direction of stimulation. The left centre 
is therefore the more active and there results a strong slow movement 
of both eyes to the right. 

The following diagram shows the result of aspiration of the 
same canal (Fig. 236) : — 

After aspiration the cilia will be directed toward the non-ampul- 
lated end, which in the horizontal canal is the direction of inhibition. 
The left centre being inhibited, the right overbalances and becomes 
weakly positive. The result is therefore a weak, slow movement to 
the left. 

When the fistula is in the superior canal, the results of compres- 
sion and aspiration can be reasoned out as above. As mentioned 



PURULENT LABYRINTHITIS. 327 

before, the effect of compression and aspiration, when the fistula is in 
the neighborhood of the oval window, is more complicated, and the 
eye movements will depend upon whether the superior or horizontal 
canal is affected. 

Galvanic Tests. — In the rotation, caloric and fistula tests 
nystagmus results from stimulation or inhibition of one of the centres 
by change of position of the ampullary cilia. In the galvanic tests no 
such change of direction of cilia follows, but nystagmus results from 
altered electrical tension of one or other of the centres by conduction 
along the vestibular nerve. If one electrode be held in the hand and the 
other applied in front of the tragus, nystagmus and vertigo will be 
produced. 

Living tissue, muscle, nerve centre, etc., is in a state of catelectro- 
tonus. In making the tests the ordinary wall cabinet with milliampere- 



tl vsT A6" u * roj ^^ 




.KATHODE APPLIED 
IE FT- VEST -AP 1 1 j| T0 

^RlSHT VEST' AP- 

Fig. 237. 

meter and pole switch is employed. One electrode is held in the hand 
and the other is applied in front of the tragus. The sponges, the hand 
and the area in front of the ear must be thoroughly moistened with 
normal salt solution. 

The examiner as in the other tests must throw the Jight from his 
head-mirror on the eye, must raise the upper lid and be on the watch 
for the first appearance of the nystagmus. The current is turned on 
and gradually increased until nystagmus appears. The reading of the 
meter is noted as well as the direction of the nystagmus. The poles 
are then reversed and the same procedure followed. The other ear is 
then investigated in exactly the same way. Whichever pole is applied 
in front of the tragus, the nystagmus will always be to the cathode. 
Remembering that the centres are in a state of catelectrotonus, this is 
diagrammatically represented for both poles in Fig. 237. 

Before the current is turned on, both centres are equally balanced 
in a state of catelectrotonus. The cathode is now applied to the right 
ear. There results a disturbance of 4 balance in favor of the right 
centre. Applying Hoegye's law, there follows a series of slow move- 



328 THE MIDDLE EAR. 

ments to the left, with cortical corrections to the right, or rotatory- 
nystagmus to the right, or nystagmus to the cathode. Application of 
the anode to the right ear is shown in Fig. 238. 

On the application of the anode to the right ear the catelectro- 
tonus of the right centre is diminished and a disturbance of balance 
between the centres results, in favor, however, of the left. The slow 
movement is therefore to the right and the nystagmus to the left. The 
anode having been applied to the right ear, the nystagmus is away from 
the anode — that is, it is as before, to the cathode. 

In normal cases nystagmus will be brought about on the application 
of the cathode by an equal amount of current on each side, and on the 
application of the anode by an equal amount on each side. 

Six milliamperes is the average amount necessary to produce 




h 



fj ANODE APPLIEO 
^ TO 
U VESTIB-A PPARATS R- VtSTI B- APPARATUS 

Fig. 238. 



nystagmus when the cathode is applied, and 8 or 9 milliamperes the 
average amount when the anode is applied. The cathodal and anodal 
amounts on one side should exactly balance the cathodal and anodal 
amounts on the other. 

In the early period of a labyrinthine suppuration, galvanic reactions 
may be obtained even when the rotation and caloric reactions are nega- 
tive. Later, however, degeneration of the vestibular nerve follows 
destruction of its end organ, and when this has occurred the galvanic 
reactions will not be elicited. If a vestibular apparatus be destroyed 
the centre on that side either is weakly catelectrotonic or anelectro- 
tonic. With one labyrinth destroyed the average milliamperage neces- 
sary to produce nystagmus is for the cathode 10 and for the anode 4. 
With one labyrinth hyperesthetic the average milliamperage is for the 
cathode 1 and for the anode 11 or 12. 

•The electrode which is applied in front of the tragus should be 
fitted with a "make and break" mechanism. 

The following tables, devised by Dr. George W. Mackenzie, show 
the comparison of the cathodal and anodal opening and closing nystag- 
mus : — 



PURULENT LABYRINTHITIS. 

1. Normal nerve : — 

K C N > K O N 

A O N > A C N 

2. Vestibular apparatus destroyed : — • 

K O N > K C N 
A C N > A O N 



329 



SECTION II. 

General Remarks. — The labyrinthine capsule is composed of 
dense, hard ivory bone, part of which — the outer (lateral) wall — forms 
the mesial wall of the tympanic cavity. The labyrinth is the 




Fig. 239. — Mnemonic diagram of the canalicular system of the right 
side, a, The ampulla of thV horizontal semicircular canal, b, The ampulla 
of the anterior vertical (superior) canal, c, The ampulla of the posterior 
vertical (posterior) canal, d, The confluence of the two vertical canals. 
e, The convexity of the horizontal canal. /, The convexity of the anterior 
vertical canal, g, The convexity of the posterior vertical canal. (From 
Barany's "Physiologie und Pathologie des Bogengang-Apparates Beim 
Menschen," with permission.) 

wonderful organ of equilibrium and also of sound perception. The 
hardness of the capsule and its anatomical structures seem to be so 
arranged by nature that they form an unusually strong barrier 
against invasion by purulent processes. It is estimated by Bezold 
that the labyrinth becomes involved in the necrotic process only 
once in 500 cases of chronic purulent otitis media. Friedrich and 
Hinsber?, on the other hand, estimate its occurrence once in 100 
cases. Many cases occur during the first ten years of life and pass 
unrecognized (Lafayette Page). 

The most vulnerable points in the labyrinthine wall are the 
horizontal semicircular canal, the fenestra ovalis, the fenestra 



330 



THE MIDDLE EAR 



rotunda, the promontory, and from the cranial side the internal 
auditory meatus. 

The mnemonic diagram of the canalicular system of the right 
side devised by Barany |Fig. 239) is a valuable aid to the proper 

































■ 






























tr 


*-!"" 






i 


Am 


.-v .',... 










^©©.srs^srv 



Fig. 240. — Dissection of the temporal bone, with key plate, in which 
the mastoid and zygomatic cells have been entirely excavated, the Fallopian 
canal opened, the semicircular canals uncapped, and a portion of the 
petrous portion cut away, depicting the relation of the canalicular system 
to the facial nerve, the mastoid antrum, the internal auditory meatus and 
the carotid canal. (From Dr. William M. Dunning's collection of 
temporal bones.) 

understanding of the relation of these important structures. The 
relation of the semicircular canals to the facial nerve, the mastoid 
antrum, the carotid canal and the internal auditory meatus is shown 
in the accompanying dissection of the temporal bone (Fig. 240). 



PURULENT LABYRINTHITIS. 



331 



The relation of the semicircular canals to the middle cranial fossa, 
to the sigmoid sinus, to the facial nerve, and to the oval window is 
depicted in the dissection shown in Fig. 241. 



MECHANICS AND MODE OF INVASION, WITH RELATIVE 
PATHOLOGIC NOTES. 

The labyrinth may be invaded by a purulent process from 
three sources : (a) from the tympanic cavity ; (b) from the blood- 
currents within the labyrinth ; (c) from the meninges. 



POSTERIOR SEM1CR CANAL 

SUPERIOR 

EXTERNAL 




INTERNAL 
'AUDIT- MEATUS 



FAC I ALNERVE CANAL 
MASTOID TIP 



JUGULAR FOSSA 



Key plate for Fig. 240. 

(a) Invasion from the Tympanic Cavity. — When the middle- 
ear spaces are the seat of a purulent lesion, it is possible that the 
labyrinth may become involved through what Boenninghaus calls 
a "collateral hyperemia." The majority of all cases, however, do 
not originate in this manner, the most common origin being that 
found in cases where a chronic middle-ear suppuration advances 
and during its progress attacks the labyrinthine wall and finally 
invades the delicate structures within the labyrinthine capsule. 
This tvpe of labyrinthitis is observed with greater frequency among 
those cases of chronic purulent otitis media in which cholesteatoma 



332 



THE MIDDLE EAR. 



is the dominant factor in the middle-ear lesion. Tuberculous and 
postscarlatinal chronic purulent otitis media also produce many 
cases of this typo of purulent labyrinthitis. 

Finally, when the chronic otorrhea is the clinical manifestation 
of chronic suppuration of the mucous membrane only, the labyrinth 
is rarely invaded. 




Fig. 241. — Deep dissection of the temporal bone, with key plate. The 
Fallopian canals have been uncapped, depicting the relation of the latter 
to the middle cranial fossa/, the sigmoid sinus, the facial nerve, the jugular 
bulb and the oval window. (Author's collection.) 



(b) Invasion from the Blood-vessels. — The intimate vascular 
connection between the lateral sinus and the petrosal sinuses and 
the labyrinthine vessels renders very possible infection of the 
labyrinth along these venous channels by metastasis and without 
the production of fistulous openings in the labyrinthine capsule. 1 
However, such an invasion through the blood-stream is rare 
and when it does occur usually it is found among those affected by 



1 Page, Transactions of the American Laryngological, Rhinological and 
Otological Society, 1909. 



PURULENT LABYRINTHITIS. 



333 



syphilis. Among the cases occurring in persons in the secondary 
stage of syphilis the symptoms show a distinct nerve deafness, 
which may or may not be accompanied by vertigo. Boenninghaus 
deems it doubtful whether or not this type of labyrinthitis is a true 
labyrinthitis or simply a neuritis of the auditory and vestibular 
nerves. On the other hand, in the tertiary stages of syphilis 
Downie found the labyrinth filled in with bone deposits, and 




OVAL WINDOW 
ROUNOWtNOOW 



Key plate for Fig. 241. 



Manasse observed new connective-tissue formation within the 
perilymphatic spaces in addition to a neuritis of the acoustic nerve. 

The cases of labyrinthitis which accompany hereditary syphilis 
usually are non-purulent ; both ears are involved, and the patients 
exhibit Hutchinson teeth, and also significant scars and ulcers 
within the nares and the mouth, and additionally show characteris- 
tic signs upon the skin. In doubtful cases the Wassermann or the 
Noguchi blood test (see page 435) furnishes additional data. 

(c) Invasion from the Meninges. — This type of labyrinthine 
invasion results in deafmutism. Deafmutes of this type have 
suffered from an acute infection of the meninges, either in the form 
of meningitis purulenta or epidemic cerebrospinal meningitis, from 



334 THE MIDDLE EAR. 

which they have emerged with more or less impairment of the 
labyrinthine function. 

According to the observation of Habermann, the infection 
invades the aquaeductus cochleae and progressively involves the 
lymph channels and the acoustic nerve, thereby producing primary 
infection of the endolymph spaces, or primarily involving the 
perilymphatic spaces. 

The loss of labyrinthine function is immediate, but, because for 
the most part the victims are children, the destructive lesion in the 
labyrinth is not immediately recognized. 

The cases, however, which mostly interest us here are those 
in which the purulent process progresses from the middle-ear 
spaces into the labyrinth. Deafmutism and the non-purulent dis- 
eases of the labyrinth are elsewhere discussed (Chapter XXVIII). 

GENERAL PATHOLOGY. 

Purulent labyrinthitis presents, pathologically, a destruction 
of part of the labyrinthine capsule, and a total or partial destruc- 
tion — according to the stage at which the lesion is examined — of the 
structures of the membranous labyrinth. The principal lesion may 
be located at one or at both of the labyrinthine windows, from 
whose recesses pus exudes. Where the oval window is the seat of 
the lesion the annular ligament and footplate of the stapes may be 
entirely destroyed ; or there may be a defect through which pus 
exudes and around which granulation tissue may be massed. 
These structures may all be destroyed and an opening left, through 
which purulent secretions pass freely from the middle ear into the 
vestibule of the labyrinth. There is every reason to suspect, logic- 
ally — although from its more hidden position it is less likely to 
exhibit evidence of its existence — that the round window commonly 
plays a part as the entrance seat of the invasion. 

The continuity of the labyrinthine capsule is often broken at 
the most prominent portion of the horizontal semicircular canal. 
These lesions are of varying sizes, from small perforations to large 
defects. 

The promontory rarely presents a fistulous opening, according 
to Friedrich (1909). Where such a fistula is found granulation 
tissue usually surrounds the opening, and through the masses of 
granulations the pus oozes into the tympanum. 

Among the cases wherein the labyrinth becomes invaded from 
the cranial side, we find, pathologically, that there is a marked 
enlargement of the labyrinthine spaces, and the fistulous openings 
break from within the labyrinth outward. 

Again, when necrosis is the predominating lesion in the dis- 
ease of the tympanic cavity, the labyrinth is often found to be 
destroyed, to a greater or less extent. When this is the pathological 
finding the case is designated as one of "panotitis." 

The purulent process in the labyrinth may either be diffuse or 
circumscribed, — in other words, it may affect the whole mem- 



PURULENT LABYRINTHITIS. 335 

branous labyrinth, or involve only a part of this structure. When 
the latter condition is present it is not unusual to find the remainder 
of the labyrinth walled off from the infection. This latter finding- 
is the rule whenever the lesion involves the horizontal semicircular 
canal. In the majority of cases the purulent process is barred 
from the cranium, through adhesive processes in the perineural 
and perivascular lymph spaces. In such cases the brain and 
meninges are cut off from intercommunication with the labyrin- 
thine fluid, and, finally, as shown in the syphilitic cases, new con- 
nective-tissue deposits and also new bone formation may occur, 
which circumscribe the purulent process and act as barriers against 
its advance toward the cranium. 

In another group of cases the process has been so acute that 
nature has not been permitted to establish barriers to the advance 
of the infection. Not only does diffuse labyrinthitis result, but the 
meninges and cerebellum are liable to become infected, with a 
resulting meningitis or cerebellar abscess. 

COURSE OF THE DISEASE. 

It is not to be expected that the functionating labyrinth once 
destroyed can ever be restored. However, the cessation of the 
purulent process not only is possible, but often does occur even 
without surgical intervention. Hinsberg holds, that postscarla- 
tinal labyrinthine suppuration tends to heal, an observation sub- 
stantiated by Boenninghaus in the study of deafmutes in the 
Breslau Deafmute Asylum. 

When cholesteatoma is the predominating factor, spontaneous 
healing — that is, cure without resort to surgery, is less probable. 

In cases of diffuse labyrinthitis — that is, where no encapsula- 
tion takes place, and prompt relief is not obtained through surgical 
means, death speedily ensues from meningitis or brain abscess. 
This is the rule in cases of acute labyrinthitis which are induced 
by acute purulent otitis media. Where encapsulation takes place 
(circumscribed labyrinthitis) any operative procedure on the middle 
ear, the necessary employment of the chisel during the technique 
of the radical mastoid operation where extensive eburnization is 
present, the injudicious use of the probe during examinations or at 
the operating table, all these are factors which by destroying 
protective barriers and breaking down adhesions may arouse into 
activity the encapsulated process and thus convert the circum- 
scribed labyrinthitis into one of the diffuse type precisely as the 
latent and encapsulated brain abscess through similar measures is 
aroused into activity. Zeroni reported having collected 40 cases of 
labyrinthitis, in 75 per cent, of which their activity was thus 
aroused. 

The eighth nerve (nervus acusticus), formerly considered one 
nerve, is now recognized as two distinct entities : (a) the cochlear 
nerve and (b) the vestibular nerve. The former, distributed finally 
to Corti's organ, is the nerve of hearing, and the latter, distributed 



336 THE MIDDLE EAR. 

to the vestibule and semicircular canals, is concerned with the 
functions of orientation and equilibrium. 

Purulent invasion of the labyrinth disturbs or destroys the- 
functional activity of the nerve. In the early stages of the disease 
the symptoms are the direct result of irritation to the organs con- 
trolling equilibrium and orientation, and also disturbance of the 
auditory function. 1 ater. the symptoms are due to complete de- 
struction of the end organs of both cochlear and vestibular branches 
on the affected side, or to the unbalanced action of the vestibular 
component of the labyrinth on the opposite or unaffected side of the 
head. The symptoms which are evoked by interference with the 
vestibular apparatus and the experimental ( diagnostic) tests of the 
labyrinthine functions are described in Section I of this chapter. 

The student should here note that nystagmus, vertigo and dis- 
turbances of. equilibrium are either spontaneous or induced. AYhen 
they are the result of disease and are exhibited by the patient 
when he presents himself for examination, they are spontaneous. 
When we elicit them by the application of our rotation, caloric or 
other tests, they are induced or experimental. 

THE CLINICAL PICTURE. 

The details of the clinical picture may be grouped as : (a) 
general symptoms, such as fever, headache, nausea, and vomiting, 
and ( b) special symptoms, such as tinnitus, deafness, co-ordination 
disturbances, facial paralysis, and the objective signs obtained, as 
described, by the rotation, caloric, fistula, and galvanic tests. 

General Symptoms. 1. Fever. — There is no characteristic 
temperature curve in purulent labyrinthitis. Neither is there in 
individual cases any relation between the temperature curve and 
the extent of the purulent invasion of the labyrinth. At some time 
during the progress of the disease, providing the temperature is 
regularly recorded, some rise of temperature will be found. On 
the other hand, subnormal temperatures are recorded at varying 
periods. The temperature curve, therefore, is not a distinctive 
symptom of purulent labyrinthitis. 

2. Pain. — Dull headache which is referred to the region of the 
diseased temporal bone, but not of marked severity or constancy, 
usually is present — at least at some time during the progress of 
purulent labyrinthitis. According to several observers, violent, 
lancinating pain is experienced by patients during the period 
required for sequestration of a necrosed labyrinth. 

3. Nausea and Vomiting. — Attacks of nausea and vomiting are 
almost invariably observed as early symptoms of purulent laby- 
rinthitis. According to Bezold, vertigo and nausea usually occur 
as symptoms of the early stage of necrosis of the labyrinth; hence, 
when occurring in cases of prolonged chronic suppuration of the 
middle ear, they may be considered as suggestive of incipient 
labyrinthitis. 

As the disease in the labyrinth progresses and the terminal 



PURULENT LABYRINTHITIS. 



337 



nerve fibres in the ampullae become destroyed, the tendency to 
nausea and vomiting is lessened. 

Special Symptoms. 1. Tinnitus Aurium. — Contrary to the 
importance which tinnitus aurium assumes in non-purulent affec- 
tions of the labyrinth, this symptom is neither always present nor 
constant in the purulent form. In Bezold's record of 41 cases but 
3 complained of tinnitus, the absence of which has been explained 
by Friedrich upon the assumption that, "with the gradual develop- 
ment of the clinical symptoms of labyrinthitis, supplementary ear 
noises do appear in the beginning as 'irritation symptoms,' which 
later on disappear with the destruction of the nervous apparatus." 




Fig. 242. — Author's noise producer. The box (which is not shown 
in the cut) contains an ordinary telephone appliance connected up 
with a dry-cell battery and faradic coil. From the receiver a section 
of soft-rubber tubing conducts the sound to a hollow glass ear piece. 
By inserting a >- into the main section of the rubber tubing the 
sound may be conducted to both ears simultaneously. 



2. Impairment of the Hearing Function.— Here we have a symp- 
tom which almost invariably is present whenever the labyrinth 
becomes the seat of purulent inflammation. In the majority of 
instances the hearing function in the affected ear not only is 
seriously impaired but completely destroyed, depending upon 
whether the labyrinthitis is circumscribed or diffuse. In Gerber's 
record of 67 tabulated cases 43 showed complete loss of the hearing 
function, and in the remaining 22 cases only a remnant of the 
hearing function survived. The tests show impairment or loss of 
bone conduction on the affected side, and Weber positive toward 
the opposite ear. Whenever the purulent invasion is confined to 
the semicircular canals the impairment of the hearing function is 



338 THE MIDDLE EAR. 

partial, but deafness becomes complete when the cochlea is totally- 
destroyed. 

In determining the total loss of the hearing function in an 
ear which is the seat of labyrinthitis, it is necessary to eliminate 
the hearing function of the opposite (normal; ear by means of a 
noise producer (Figs. 242 and 243). 

3. Disturbances of Co-ordination. — These are vertigo, nystagmus 
and ataxia. Authorities differ as to the constancy of vertigo, 
nystagmus and nausea when regarded as symptoms of purulent 
labyrinthitis. Bezold believes that they are present in the majority 
of all cases during some stage. Gradenigo, on the contrary, 
contends that these symptoms are by no means constant. He 
furthermore observes that, when the lesion is confined to the 

cochlea, nystagmus, vertigo and nausea 
usually are absent. In other words, the 
disturbances of co-ordination are present 
when the purulent disease is located 
in the semicircular canals or vestibule. 
Friedrich substantiates the views of 
Bezold and believes that, barring impair- 
ment of the hearing function/ disturb- 
ances of co-ordination are the most promi- 
nent and constant of the symptoms of 
purulent labyrinthitis. Jansen found ver- 
tigo in 72 per cent., Lucae in 60 per cent., 
and Hinsberg in 86 per cent, of their cases 
Fig. 243.— Barany's noise of purulent labyrinthitis. The various 
producer. diagnostic tests are fully elaborated in 

Section I of this chapter. 

4. Facial Paralysis. — The advent of facial paralysis in con- 
nection with a long-standing purulent otitis media is not neces- 
sarily to be considered as indicative of labyrinthine involvement. 
Nevertheless, occasionally it does occur in connection therewith. 
In 27 cases of labyrinthine suppuration reported by Friedrich facial 
paralysis occurred three times. It therefore possesses diagnostic 
significance only when associated with the more common symptoms 
of the affection. 

Finally, the operative findings during the course of the radical 
mastoid operation often furnish a guide to the diagnosis of purulent 
disease of the labyrinth. 

PROGNOSIS. 

According to Hinsberg, the mortality of purulent labyrinthitis 
is from 15 to 20 per cent. The great majority of those who die 
succumb to meningitis. - 

The prognosis in cases of circumscribed labyrinthitis is more 
favorable. According to Scheibe, the mortality of labyrinthitis 
caused by tuberculosis also is less than that reported by Hinsberg. 




PURULENT LABYRINTHITIS. 



339 



TREATMENT. 

The treatment of purulent labyrinthitis is mainly surgical. 
The nature of the surgical procedure varies with the lesion present. 
Many competent observers consider it unnecessary to open the 
labyrinth, except in markedly severe cases. These authorities con- 
tent themselves with the performance of the radical mastoid opera- 
tion, and from such a procedure alone they have reported excellent 
and satisfactory results. 

Heine 2 believes the operation on the labyrinth should be 
limited to those cases wherein we are positive of the presence of 
pus. Furthermore, Heine limits his procedure to the curetmertt of 
defects in the semicircular canals, and even Jansen saw but one 
death in 121 cases thus treated from 1889 to 1896. 

Indications for Opening the Labyrinth. — The following, 
together with the explanatory notes, outlines the indications and 
contraindications for operating upon the labyrinth. The plus signs 
show presence of hearing and vestibular irritability, and a positive 
fistula test. The minus sign denotes their absence. 

Neumann's Chart. 





Cochlea 


Vestibular 
Apparatus 


Fistula 


Spontaneous 
Nystagmus 


Operation 


I 


+ 


+ 


+ 


{- 


None 
None 


II 


- 


+ 


+ 


{- 


If necessary 
None 


III 


+ 


- 


+ 


{1 


Operation 
If necessary- 


IV 


+ 


- 1 " 


{± 


Operation 
If necessary 


V 


- 




+ 


{- + 


Operation 
Operation 


VI 


- 


- 


- 


{± 


Operation 
Operation 


VII 


- 


+ 


- 


{± 


None 
None 



/. This is very evidently circumscribed, whether spontaneous nystag- 
mus be present or absent, and the radical mastoid operation alone is indicated. 

II. If no spontaneous nystagmus is present and the vestibular apparatus 
is functionating, the disturbing process is circumscribed and confined to the 
cochlea and no labyrinth operation is indicated. The occurrence of spon- 



'Operationen am Ohr. 



340 THE MIDDLE EAR. 

taneous nystagmus may be the evidence of the involvement of the ves- 
tibular apparatus and the indication for the labyrinth operation. 

///. The hearing remains, the vestibular apparatus is not frnctionating 
and a fistula is present. This is evidently circumscribed and confined to the 
vestibular apparatus and no labyrinth operation is necessary unless evidence of 
extension supervenes. 

IV. The hearing remains, the vestibular apparatus is not functionating, 
the fistula test is negative. This is also circumscribed and no labyrinth 
operation is indicated. If spontaneous nystagmus be present it is evidently 
due to overbalance of the centre on the sound side, and would not of itself 
determine operation. Evidence of extension : i.e., complete loss of hearing 
would be the operation indication. 

V. Hearing lost, vestibular apparatus destroyed, fistula positive. Op- 
eration indicated with or without spontaneous nystagmus. 

VI. Hearing lost, vestibular apparatus not functionating, the labyrinth 
operation is indicated. 

VII. The hearing lost, but the vestibular apparatus is functionating, 
and there is no fistula; hence the labyrinthine operation is not indicated. 

In the absence of symptoms more serious than functional 
defects in the labyrinth, several considerations must be taken into 
account when deciding upon the necessity for the labyrinth opera- 
tion. We should endeavor to differentiate between circumscribed 
and diffuse labyrinthitis. The mode of onset of the deafness, 
whether sudden or gradual, is also of importance in determining 
the necessity for operation. Total deafness of long duration may 
be the result of pressure from cholesteatoma or secondary to 
changes in the bony capsule, and not necessarily the result of acute 
infection of the cochlea. If the vestibule is irritable and spon- 
taneous nystagmus is toward the affected side, the labyrinth opera- 
tion should not be perfornied, but the radical mastoid operation is 
indicated to prevent extension of an evident perilabyrinthitis to 
the labyrinth itself. On the other hand, if the hearing is com- 
pletely destroyed by an acute invasion, operation is imperative if 
the vestibule is not irritable. If the spontaneous nystagmus is 
toward the affected side and the hearing remains, operation may 
be deferred until the spontaneous nystagmus changes or loss of 
hearing indicates complete involvement of the labyrinth. 

Operations on the Labyrinth. — The operations on the labyrinth 
have for their purpose similar objects — the opening of the labyrin- 
thine channels and the establishment of drainage therefrom. 

The operations of Jansen and Neumann are very similar. 
That of Hinsberg is slightly different in the method of approaching 
the operative field. Richards enters the vestibule from behind but 
does not remove the section of bone (Trautmann's triangle) lying 
between the sigmoid sinus and the labyrinth. 

Briefly described, the Hinsberg operation consists of the fol- 
lowing technical steps : — 

1. The thorough performance of the modern radical mastoid 
operation. 

2. The procedures on the labyrinth proper. They are as 
follows : The bone between the oval and the round windows is 
removed by the use of a small burr or a small hollow gouge (2 
mm.). This opens the lowest turn of the cochlea. The space thus 



PURULENT LABYRINTHITIS. 341 

gained is widened by taking away bone until the crest containing 
the facial nerve is reached above. Toward the front the bone is 
carefully removed until the region of the carotid artery is impinged 
upon. Additionally, a second opening is made, entering the 
exposed ampullae of the superior and horizontal semicircular canals 
and removing the roof of the vestibule. The canals are opened as 
extensively as is consistent with- the structure. A bridge of bone is 
left between the horizontal semicircular canal and the oval window 
as a guard for the facial nerve, although injury to the nerve is 
rather common in this method of operating. 

The Jansen-Neumann technique comprises measures which 
begin by the removal of that portion of the mastoid process which 
lies between the anterior margin of the sigmoid sinus and the 
horizontal semicircular canal (the Trautmann triangle). Working 
from below, the posterior semicircular canal is first attacked. The 
position of this canal is detected by the appearance of two small 
openings which diverge as more bone is removed. Proceeding 
upward the crus commune and horizontal canal are found and the 
vestibule opened under the aqueduct. 

By this means of operating the semicircular canals are suc- 
cessively removed and the labyrinth is opened at the vestibule from 
behind. Furthermore, the cells which are deeply situated between 
the cerebellum and the semicircular canals (Trautmann's triangle) 
are fully exposed and removed. 

In the following personal communication (translated), Neu- 
mann states his more recent views concerning the technique of the 
labyrinthine operation : — 

"The labyrinth operations may be divided into, 1, those in which 
the vestibule is opened through the prominence of the horizontal 
semicircular canal and the promontory is opened up through the 
tympanic cavity, and, 2, those in which the labyrinth is opened from 
the posterior surface of the pyramid." 

The later method practised by Neumann is accomplished as fol- 
lows: "After exposing the dura of the posterior cranial fossa in front 
of the sinus, the posterior surface of the pyramid is ablated in 
layers, the chisel held parallel with the posterior semicircular canal, 
which is recognized by the two circular transverse sections of the 
same. Now more of the pyramid substance is ablated and so a 
third opening appears between the other two. This third opening" 
is the non-ampullated end of the horizontal semicircular canal. 

"By exploration with a sound one can easily be convinced that 
a cavity is reached through the opening and this cavity is the 
vestibule. With gentle taps on the chisel this opening is grad- 
ually widened until the vestibule is opened up sufficiently. By 
also chiseling away the bony projection situated toward the median 
line, we reach the dura which dips into the inner auditory canal. 
By ablating the promontory below the facial, the cochlea is widely 
opened and a bent probe entering the vestibule will appear in the 
tympanic cavity. 

"This technique evolved itself gradually, and only recently did 



342 THE MIDDLE EAR. 

I feel myself compelled to expose the dura of the posterior cranial 
fossa in front of the sinus in all cases, although in a great number 
of cases I had been successful in opening, the vestibule without 
exposing the dura at the internal auditory meatus, according to 
the method described above. 

"The circumstance that justifies the new operation is that it is 
more radical and less dangerous both for the facial nerve and the 
dura, even though the latter is exposed. 

"The after-treatment is an open one until the retrolabyrinthine 
cavity is entirely filled with granulations, and now the wound may 
be closed by secondary sutures." 

Care must be exercised in carrying out this procedure or the 
superior petrosal sinus may be injured, and also in breaking away 
the rear border of the petrosal pyramid, for when the dome of the 
jugular bulb lies high this structure may accidentally be injured. 

The Jansen-Neumann operation is indicated more particularly 




\ 

Fig. 249. — The modiolus. The base of the modiolus is excavated by 
the anterior auditory meatus and in consequence is extremely liable to 
fracture as a result of injudicious chiseling about the cochlea shell. 

when the symptoms furnish evidence of meningitis or deeply situated 
extradural or cerebellar abscess, since its technique lays bare the cranial 
structures which are involved in these lesions. 

Boenninghaus admonishes against curetment of the opened 
labyrinth, inasmuch as it is conceivable that such a procedure 
might destroy adhesions which are acting as a barrier to the 
advance of the purulent invasion toward the cranium. 

The technique described by Richards 3 comprises the following 
steps illustrated from the paper referred to : — 

1. Complete the radical mastoid operation (Fig. 191). In 
addition to the usual procedure, the hypotympanum and lower level 
of the external canal floor are planed off to expose to its utmost 
the outer wall of the vestibule and the dome of the jugular bulb. 
Likewise, the orifice of the Eustachian tube must be fully exposed, 
and wherever possible the arches of the semicircular canals outlined 
(Fig. 244). 

2. The prominence of the horizontal semicircular canal is now 
removed, using a very small narrow chisel for this purpose. The 
point of election is usually well above the Fallopian canal and just 



3 Transactions of the American Laryngological, Rhinological and Oto- 
logical Society, 1907. 




Fig. 244. — Extensive excavation of bone preliminary to the operation 
upon the labyrinth. ( Richards, with permission.) 




Fig. 245. — The semicircular canals have been uncapped. A probe 
has been introduced into the superior canal and the tip protrudes from 
the oval window. {Richards, with permission.) 




Fig. 246. — The vestibule has been opened through the solid angle of 
the semicircular canals and the Fallopian canals. (Richards, with per- 
mission.) 




Fig. 247. — The anterior inferior wall of the vestibule has been removed 
by chiseling the section of bone which separates the oval and round win- 
dows. The roof of the first whorl of the cochlea also has been removed. 

(Richards, with permission.) 




Fig. 248, 



-Extensive excavation of the cochlea 
(Richards, with permission.) 



shell. 



PURULENT LABYRINTHITIS. 343 

below the summit of the semicircular canal wall. A few light taps 
of the chisel uncap the semicircular canal. 

3. The other canals are then uncapped (Fig. 245). 

4. The vestibule of the labyrinth is now entered through the 
solid angle (Fig. 246). This opening is gradually enlarged by using 
a chisel held perpendicular to the line of cleavage. The bridge of 
bone which forms the covering of the facial nerve at this point is 
left untouched. 

5. The vestibule open, its inner wall is searched for fistulse. 

6. The cochlea is now exposed, using a gouge whose width 
equals the distance between the oval and the round windows. The 
opening thus made is enlarged until the first turn of the cochlea is 
fully exposed (Fig. 247). 

7. The roof of the first turn is now removed to a point just 
short of the carotid eminence, and further exploration of the coch- 
lear shell follows. 

8. The point selected to effect an entrance in this step is taken 
on an estimate as to where the apex of the cochlea is supposed to 
be. The bone is gradually shaved down until the interior is seen 
through the thinned bony covering, when, by means of a chisel 
stroke delivered from above downward and forward, the opening 
is effected. Occasionally the extent of the necrosis requires more 
extensive removal of the cochlear shell (Fig. 248). During the 
removal of the first cochlear whorl it is important that the modiolus 
(Fig. 249) shall not be punctured at its base. 

This completes the operation. Having completed the procedure, 
the labyrinthine wound should be lightly packed with gauze, and 
the remainder of the mastoid wound packed similarly to that 
described under the dressing of the mastoid wound (page 246). 



CHAPTER XXIV. 

COMPLICATING LESIONS OF PURULENT OTITIS MEDIA. 
{Continued.) 

THE INTRACRANIAL COMPLICATIONS OF PURULENT 
OTITIS MEDIA. 

PHLEBITIS AND THROMBOSIS OF THE BLOOD-VESSELS. 

(Lateral Sinus-thrombosis.) 

Preliminary Considerations. 

In the preceding chapters relating to purulent otitis media we 
have traced the course of the infective process from the tympanic 
cavity into the pneumatic cells of the mastoid process and other 
portions of the temporal bone. 

In addition, we have shown that the ravages of the infection 
within the bone, whether of the acute or chronic form, may usually 
be terminated by timely operative interference upon the part of the 
aural surgeon. 

Furthermore, the surgical procedures whereby the ra\ages of 
the infection within the bone, whether in the acute or chronic form, 
can usually be terminated have been illustrated and defined. 

There remans a small percentage of cases of aural suppuration 
wherein the infection penetrates the inner (visceral) cranial table 
and subsequently invades the lateral sinus (Fig. 254), meninges or 
brain (Fig. 262). 

In view of the comparative thinness of the inner (cranial) table 
of the temporal bone, areas of which are often bathed with pus for 
long periods of time, one marvels that, proportionately, so few intra- 
cranial complications occur. 

During recent years a distinct advance has been made in our 
knowledge of the etiology, diagnosis and treatment of the intra- 
cranial complications of purulent otitis media, and the investiga- 
tions connected therewith have clearly demonstrated that, barring 
traumatism, epidemic cerebrospinal and tuberculous meningitis, the 
majority of all cases of intracranial infections originate in the ear. 
The nasal accessory sinuses also furnish a small percentage of 
meningeal infections. The treatment of these complications there- 
fore very properly comes within the domain of the aural surgeon. 

Erosions of the inner (visceral) table of the temporal bone may 
occur at any point, but they are more commonly found in the tegmen 
and about the knee of the sigmoid sinus. 

Necrosis of the inner table, even when considerable areas of 
the dura are exposed to the purulent processes which invade the 
mastoid process, is not invariably followed by grave intracranial 
infection. Erosions of the inner table with exposure of the dura 

(344) 



LESIONS OF PURULENT OTITIS MEDIA. 345 

are discovered with comparative frequency during the progress of 
mastoid operations, with no subsequent sequelae pertaining to 
intracranial infections, showing that the dura in many instances 
seems to possess considerable resistance to the contact of infection. 

The Relative Frequency of the Intracranial Complications 
of Otitic Origin. 

The following statistics pertaining to the relative frequency of 
intracranial complications of otitic origin are worthy of con- 
sideration : — 

Hassler compiled the intracranial complications from a total 
of 81,684 cases of diseases of the ear, from which number there 
were 116 deaths from intracranial extension, classified as follows: — 

Meningitis 40 

Sinus-thrombosis 48 

Cerebral abscess 28 

Korner^ compiled the results of 115 autopsies where death had 
been due to otitic infection of the meninges, and found 

Meningitis in 31 

Sinus-thrombosis in 41 

Brain abscess in 43 

Pitts's report covering 9000 consecutive autopsies at Guy's 
Hospital, London, between 1869 and 1887, shows 67 cases wherein 
death was due to intracranial disease of otitic origin — that is, 1 in 
every 158 autopsies. 

Gruber investigated the findings reported upon 40,073 autopsies 
covering deaths from all causes. Death was due to aural suppura- 
tion in 232 cases, or 1 in every 173. 

Burkner, out of 33,017 cases of aural disease of all kinds, reports 
104 deaths from the effects of aural suppuration, or 1 in every 317. 

Randall, out of 5000 cases of aural disease, reports 15 deaths due 
to aural suppuration, or 1 in 333. Dench investigated the reports 
of the New York Eye and Ear Infirmary for a period of eight years, 
during- which time 64,858 cases of aural disease were treated, and 
found that out of this number there were 218 cases of serious 
intracranial (not all fatal) complications, or 1 in every 296. 

The author compiled the statistics of the Manhattan Eye, Ear 
and Throat Hospital covering a period of seven years, during which 
29,223 cases of aural disease were treated. Of this number there 
were 118 cases (not all fatal) of serious intracranial complications, 
or 1 in every 248. 

The reports of the Manhattan Eye, Ear and Throat Hospital 
from 1895 to 1905 record 12.744 cases of purulent otitis media aside 
from other ear diseases, with 60 cases of intracranial complications. 

Meningitis 30 

Sinus-thrombosis 23 

Brain abscess 7 



346 



THE MIDDLE EAR. 



The time of life most liable to the development of serious 
lesions in chronic otorrhea, according to Korner in an account of 
100 cases, shows the following: 14 occurred under ten years of 
age; 22 between ten and twenty; 29 between twenty and thirty; 
14 between thirty and forty, and 12 over forty years of age, thus 
showing that dangerous complications occur more frequently in 
the earlier stages of life, especially between twenty and thirty 
years of age. 

Sinus-thrombosis. 

Anatomy. — The cranial sinuses are venous blood-vessels run- 
ning in the layers of the dura mater for the purpose of collecting 
and conveying the return flow of the blood from the brain. The 



F C 




Fig. 250. — Sinus bone specimen. X corresponds to point where sig- 
moid sinus is nearest to surface. The right side of Fig. II has been cut 
on the level of line C-D in Fig I. The left side of Fig. II has been cut 
on the level of line F-E in Fig. I. The vertical cut C-D was made so as 
to just clear the most posterior point of the temporal bone. The vertical 
cut F-E was made so as to pass through the thinnest portion of bone wall 
of the sigmoid sinus, as ascertained by means of calipers. 



cranial sinuses and the cerebral veins are without valves and are 
not accompanied by corresponding arteries. 

Among the largest of these sinuses is the sinus transversus or 
sinus lateralis, which on account of its course along the inner table 
of the temporal bone (Fig. 250) is the venous structure which most 
concerns the otologist. 

Anatomy of the Sinus Lateralis. — The sinus lateralis, or trans- 
versus, begins at the torcular Herophili (sinus confluens) and ends 
at the bulb of the jugular vein. The sinus has two anatomical 
divisions, taking names from the direction in space which they 
respectively occupy. That is, it is divided into a vertical and a 
horizontal portion (Fig. 251), the vertical section being termed the 



LESIONS OF PURULENT OTITIS MEDIA. 



347 



sigmoid portion of the lateral sinus, or, more commonly, the sigmoid 
sinus. The place where the horizontal segment joins that of the 
sigmoid presents a rather angular turn, which is often termed the 
"knee" of the sigmoid sinus. During its course from the torcular 
Herophili to the jugular bulb, where it merges into the internal 
jugular vein, it traverses and grooves portions of the occipital, 
parietal, and the mastoid portion of the temporal bone, and mean-, 
while receives the superior petrosal sinus, the mastoid emissary- 
vein, and the inferior petrosal sinus, the latter entering at the 
jugular bulb. 

The exact course of the sigmoid sinus varies in its relation to 
the cortex and to its approach to the suprameatal spine, and, further- 




Fig. 251. — Sinus bone specimen. (See legend under Fig. 250.) 



more, according to Korner, the sinus extends farther forward on 
the right side than it does upon the left. 

The average distance from the anterior surface of the knee of 
the sinus to the spine of Henle in 463 adult temporal bones 
measured by Held was 12 mm. In one of his cases the sinus 
impinged upon the posterior meatal wall. The author has observed 
one similar case during operation. 

The radiograph (Fig. 252) usually shows the outline of the lateral 
and sigmoid portion of the sinus. Topographically the pathway fol- 
lowed by the transverse sinus to the knee follows a line drawn from 
the occipital protuberance to the spine of Henle (Fig. 2). 

Etiology. — Thrombosis of the lateral sinus is induced either by 
means of (a) extension of the infective process within the temporal 
bone through the smaller veins, whereby the latter become involved 
with septic thrombi, which gradually extend to and infect the sinus, 
or (b) because the infection in the bone extends by contiguity, directly 



348 



THE MIDDLE EAR. 



through its internal table to the walls of the blood-vessel, where its 
farther advance is characterized by infection of the sinus walls, and 
thence into the blood-stream with resultant thrombosis. 

Furthermore, according to Boenninghaus, thrombosis may occur 
from infection located within the labyrinth. In these cases the sinus 
is usually affected below the knee, or through involvement of the 
superior or the inferior petrosal sinuses. In another group of cases 
the infection proceeds from a labyrinthine infection directly toward 




Fig. 252. — The patient whose mastoid is illustrated in the above radio- 
graph was in charge of Dr. John B. Rae at the Manhattan Eye, Ear. and 
Throat Hospital. This radiograph was taken by Dr. F. M. Law subse- 
quent to the mastoid operation. The typical symptoms of sinus involve- 
ment appeared later and a diagnosis of sinus thrombosis was made. The 
radiograph was made just before the secondary operation, and it will be 
noted that it distinctly shows, in the area below the knee in which the dots 
appear, an entirely different shading from that of the upper posterior 
portions of the sinus. This upon operation proved to be the area of infec- 
tion, but it was a pus invasion rather than an organized clot. So far as 
the author knows, this is the only radiograph in existence which shows dis- 
tinct involvement of the lateral sinus. 1, external auditory canal; 2, 
placed in two locations, indicates the outlines of the lateral sinus; 5, the 
maxillary joint. 



LESIONS OF PURULENT OTITIS MEDIA. 349 

the bulb, through involvement of the lymph spaces of the middle ear, 
or through the extension of a thrombus from the internal auditory 
vein. 

From the tympanic cavity proper a thrombosis of the jugular 
bulb may take place from direct infection through dehiscences in 
the floor of the tympanum. McKernon and others have reported 
cases of primary jugular-bulb thrombosis. Boenninghaus, Korner 
and others report cases wherein the infection entered the jugular 
bulb from the tympanic cavity proper through involvement of the 
carotid plexus, along the anterior wall of the tympanic cavity. 1 
We conclude, therefore, that phlebitis and thrombosis of any part 
of the lateral sinus and internal jugular vein take place as follows : — 

1. Through anatomical dehiscences in the bone tissue which 
covers its parietal surface, thus affording easy access to the patho- 
logic process. 

2. Through the direct extension into its walls of the active 
purulent lesion in the bone. 

3. Through involvement of the smaller veins in the diseased 
bone, or through the involvement of intermediate anastomotic veins 
in the thrombotic area. 

Pathology. — When the walls of the sinus become the seat of 
an inflammatory lesion, and when the inflammation has penetrated 
to the inner endothelial lining of the blood-vessel, it causes a 
deposit of fibrin in the lumen of the sinus, as a result of the inflam- 
mation, the fibrin being derived from the blood-current. 

This deposit is attached to the vessel wall at the site of the lesion. 
Pathologically, there results what is designated as a "white-wall throm- 
bus" (Heine, Boenninghaus). 

In the course of time this wall thrombosis grows larger and 
narrows the lumen of the vein until finally it becomes completely 
occluded. The fibrin then becomes mixed with coagulated blood, 
and assumes the form of a "red obstructive thrombosis," which may 
occlude the vessel's course for a variable distance. 

The extent of the thrombus in a backward direction may 
involve the superior petrosal sinus, the mastoid emissary vein, the 
torcular Herophili, the longitudinal sinus, and even the lateral sinus 
of the opposite side, while in the opposite direction it may involve 
the inferior petrosal and cavernous sinuses, the ophthalmic vein, and 
after traversing the jugular bulb continue throughout the jugular vein 
and its tributaries. 

Thrombi, both of the wall type and the obstructive type, may 
either be of infectious or non-infectious character, the latter occur- 
rence being more rare. 

If the thrombus is not infected it becomes organized through 
the advent of connective tissue. On the other hand, if it becomes 
infected, it eventually breaks down, spreading the infection along 
the sinus walls, and finally destroys these walls to a variable 
extent. 



1 Sec Korner, Otitischen Erkrunkinger des Herins, dcr Hirnhaute und die 

Blutlciter, 1902. 



350 THE MIDDLE EAR. 

If parts of the broken-down thrombus are carried off into the 
blood-stream, then septic emboli result. These may find lodgment 
in the lungs or other parts of the body, setting up inflammatory 
lesions at their points of lodgment. 

Symptoms. — The symptoms of lateral sinus-thrombosis are 
fairly constant, and for convenience of description are divided into, 
1 . those due to the infection of the general system, and, 2, those mani- 
fested locally. 

General Symptoms. — Of the more general symptoms of sinus- 
thrombosis the most important in typical cases is fever. Fever is 
almost a constant symptom of sinus-thrombosis, but occasionally 
even in typical cases it is absent. The fever is the result of the 
invasion of the general system, probably through the blood-streams, 
by bacteria. During the early stage of the attack the fever is 
characteristically pyemic. Usually the patient has a distinct chill, 
during which the temperature suddenly rises to 103° to 105°, but 
after a short time it recedes to normal or subnormal, only to rise 
again upon the advent of a subsequent chill, the fluctuations not 
being marked by any period of regularity (Fig. 253). As the 
temperature falls the patient sweats profusely. In the last stages 
sweating may be constant. In atypical cases the patient may 
complain of feeling chilly, and then the temperature rises to 103°, 
104°, or as high as 106°, where it remains with slight variations 
only. This is the rarer type and is generally significant of second- 
ary metastatic involvement. Vomiting of a projectile type may 
accompany the chills, but it is not a constant symptom, and, 
furthermore, it may occur in all the forms of intracranial complica- 
tions of otitic origin. 

The next most important symptom to that of fever is the 
clinical picture produced by varying metastatic lesions. According 
to Britger, these take place in 42 per cent, of the cases. The most 
common secondary lesion is that involving the lungs. This is indi- 
cated by pain in the chest and the advent of coughing. The lung 
lesion is often a bronchopneumonia. A rarer lesion is abscess of 
the lung. Then hemorrhagic sputum of foulest odor is noted. The 
infarct may lodge in the pleura, causing a pleurisy, pyopneumo- 
thorax, or the joints may become involved. The periarticular 
mucosa may be involved, and finally lesions may take place in the 
heart, the "kidneys, or the brain, each organ portraying distinctive 
symptoms. 

Headache usually is present during some period of the disease, 
and is located about the mastoid, parietal and occipital regions of 
the affected side. Swelling of the spleen also is commonly noted. 
The mentality of the patient may vary from being absolutely unaf- 
fected during the early stages to coma just preceding death. In 
general, the patients feel very sick, have no appetite, show a coated 
tongue, gradually lose weight and assume the appearance of typhoid- 
fever patients. 

Finally, the color of the skin and conjunctiva changes to a 
yellowish tinge, and the clinical picture of meningitis or brain abscess 



LESIONS OF PURULENT OTITIS MEDIA. 351 

is intensified, which continues, unless relieved surgically, to the death 
of the patient. 

Usually the disease runs its course in from eight to fourteen 
days. Cases of primary jugular-bulb thrombosis when occurring 
in infants and young children present atypical symptoms, inasmuch 
as no disease of the mastoid process is present, and, furthermore, 
the symptoms are similar to those which accompany pneumonia, 
malaria, typhoid fever, and affections of the digestive tract. In 
infants and young children the chief symptom of thrombosis of the 
jugular bulb is a sudden and rapid rise of temperature to above 
104°, followed by an equally precipitous decline. Thereafter the 
temperature curve fluctuates after the manner of the first rise, 
during which time the variations in the pulse rate follow the tem- 
perature. There is no chill, the hands and feet may be cold when 
the temperature rises; meanwhile during the earlier remissions the 
child appears quite normal, playing with its mates and taking liberal 
nourishment. 

Later on, prostration ensues and all the symptoms of sepsis 
become apparent, to be followed by a fatal issue unless an early 
diagnosis is made and prompt surgical treatment intervenes. 

Local Symptoms. — Patients having sinus-thrombosis occasion- 
ally present a swelling behind the mastoid process (the Grie- 
singer sign). This swelling or edema of the region behind the 
mastoid process usually is painful to the touch, especially at the 
mouth of the mastoid emissary vein. It seems to indicate at least 
a perisinus abscess, or a phlebitis of the mastoid emissary vein. 
This symptom is not to be considered as invariably characteristic 
of lateral sinus-thrombosis. 

Boenninghaus has noted thickening of the vena mastoidea as 
indicative of sigmoid sinus-thrombosis, and, finally, the finding of 
a rather thick strand which is painful upon pressure, or to the touch, 
along the upper portion of the jugular vein, when accompanied by 
other symptoms of the disease, is indicative of a thrombosis in- this 
vein. 

Rarer findings of a local nature have been noted in pain along 
the back of the neck. This was presented in a case where the 
thrombosis extended to the condyloid emissary veins. Edema and 
swelling in the skin of the scalp have been observed in connection 
with thrombosis of the lateral sinus, A thrombosis which extends 
to and involves the cavernous sinus induces edema of the eyelids, 
associated with chemosis and exophthalmos. Kummell found paral- 
ysis in the larynx and of the muscles of deglutition, without local 
cause, in thrombosis of the jugular- bulb. Unilateral laryngeal 
paralysis with retarded pulse has been noted in rare cases where 
the thrombus exerted pressure on the ninth, tenth, ami eleventh 
cranial nerves in the foramen lacerum posticum (Boenninghaus). 

In 1898 Voss stated that the bruit of the blood in the sinus 
ceases in cases of thrombosis. This local sign Korner (1899) sub- 
stantiated in personal observation. The bruit is listened for with a 
stethoscope, and comparison is made with the sounds heard in the 
healthy side. 



352 



THE MIDDLE EAR. 



Finally, Libman, of the Mt. Sinai Hospital, New York, has 
published observations in which he holds that the finding of strep- 
tococcus in the blood-stream, when all other possible sources of 
origin of the bacteremia are eliminated, indicates a sinus-thrombosis. 
In all of his published cases the positive findings of streptococci 
in the blood, by culturing the blood (after withdrawal from a vein), 
were substantiated at the operation by finding the sinus throm- 
botic. On the contrary, at the Manhattan Eye and Ear Hospital, 
New York, where 2 a series of blood-cultures was made from 
patients suffering from suppurative purulent otitis media, by 
Jonathan Wright and reported by Duel, the findings showed that 
in the relation of streptococcemia to sinus-thrombosis the finding 
of streptococci in the blood-stream did not indicate sinus-throm- 
bosis in all the cases in which the sinus was explored, and, further- 
more, streptococcemia was discovered in many patients with flat 
temperatures and no other coexistent signs of sinus-thrombosis. 
Nor could endocarditis or other lesions which might have accounted 
for the bacteremia be demonstrated. (The question of bacteremia 
is more fully discussed on pages 41 and 74.) 

2 Transactions of the American Otological Society, 1909. 



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Laryngological, Rhinological and Otological Society, 1909.) 



LESIONS OF PURULENT OTITIS MEDIA. 



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LESIONS OF PURULENT OTITIS MEDIA. 355 

In the present state of the subject we do not feel that we are 
justified in saying that the finding of streptococci in the blood neces- 
sarily means the existence of a sinus-thrombosis, even after all 
other sources of the bacteremia are eliminated. When, however, 
in addition to other classical signs, the blood shows streptococci 
this finding then furnishes conclusive corroborative evidence of 
the presence of a thrombus, marked leucocytosis and a high poly- 
morphonuclear percentage (page 76) being among the associated 
symptoms. 

Diagnosis. — Boenninghaus lays down the four following prop- 
ositions regarding the diagnosis of sinus-thrombosis : — : 

1. When, after an acute middle-ear and mastoid involvement, in 
spite of adequate drainage (surgical treatment) the fever recurs after 
having dropped, then we should be suspicious of sinus-thrombosis. 
Especially is this true if the temperature elevations persist over a 
number of days, and become higher as succeeding days pass. 

That fever often persists for some days after mastoid operation, 
and is especially prone to persist in the case of children, has been 
shown by Harris. 3 

2. // the fever reappears after an interval of normal temperature, 
which has follozved the procuring of adequate middle-ear drainage 
(mastoid operation, etc.). 

3. When fever suddenly reappears after a case of middle-ear 
infection apparently has been cured for some interval of time. 

4. When, in cases of chronic middle-car suppuration having mar- 
ginally situated drum perforations, there is a sudden appearance of 
fever, then sinus-thrombosis is to be suspected. 

Regarding Boenninghaus's diagnosis based upon the time and 
advent of fever, it must be borne in mind that all other sources of 
the fever first must be eliminated in order to make his four propo- 
sitions hold true. Of especial significance is this observation when 
dealing with cases occurring among children and also in cases of 
erysipelas following the mastoid operation. Erysipelas with delayed 
local manifestations is occasionally observed. In one such case occur- 
ring in the author's practice, there occurred three sudden rises of tem- 
perature ranging from 105° to 105%° on succeeding days with chills, 
nausea and other symptoms of sinus thrombosis in a patient who had 
been operated a few days previously for acute mastoiditis. The sinus 
was then opened and found normal, but upon changing the wet dress- 
ing six hours later the local symptoms, redness, swelling, etc., had 
appeared. This case made a good recovery. In one's anxiety to operate 
early, the possibility of incipient erysipelas should be eliminated. An- 
other somewhat rare postoperative condition may be defined as an 
extensive non-erysipelas cellulitis of the scalp. This is invariably 
ushered in with a sudden rise of temperature, chill and sometimes 
nausea. This may be mistaken for sinus thrombosis unless the wound 
area and scalp are examined. 



:: Annals of Otology, 1902. 



356 THE MIDDLE EAR. 

In a more detailed consideration of the diagnostic points, it is 
found that in typical cases which present the entire category of 
signs and symptoms lateral sinus-thrombosis is not difficult to recog- 
nize. The characteristic temperature curve, the chills, the sweating, 
the vomiting, the localized pain over the sinus walls, the leucocytosis, 
the high polynuclear percentage, the bacteremia, together with the 
history of purulent otitis media and mastoiditis, furnish an unerring 
clinical picture of this affection. Unfortunately, in a large percentage 
of even the so-called typical cases, one or more of the above-named 
symptoms are absent, in which event it becomes more difficult to render 
a diagnosis. (For radiography see Fig. 252!) 

In atypical cases the diagnosis always is difficult and requires 
an exhaustive consideration of the entire chain of symptoms, mean- 
while taking advantage of blood-culture, blood examinations and 
all known methods whereby other diseases may be eliminated. A 
high temperature continuing several days after a mastoid operation, 
especially when the operative findings have disclosed areas of 
necrosis of the bony covering of the lateral sinus, and examination 
of the blood shows bacteremia, leucocytosis and a high polynuclear 
percentage, is indicative at least of an infective process of sufficient 
severity to constitute sinus-thrombosis, and the sinus should be 
examined. 

The diagnosis of primary jugular-bulb thrombosis must largely 
depend upon the sudden rise in the temperature range, and the sub- 
sequent fluctuations from normal or subnormal to 104°, 105° or 
106°. Usually occurring in infants and young children, and often 
without intercurrent mastoid infection, the early diagnosis is most 
difficult and must be made only after eliminating other diseases, 
such as pneumonia, malaria, typhoid fever, and digestive disturb- 
ances. Blood examinations also furnish reliable data. 

The operative findings, both when the sinus is exposed for pur- 
poses of diagnosis and when necrotic areas of its bony covering are 
discovered during the progress of the mastoid operation, are of con- 
siderable diagnostic value, as occasionally a thrombus in the sigmoid 
region is discovered only at the time of operation. Whenever an 
exposed area of the sinus is covered with healthy granulations, its 
interior should not be disturbed unless other signs and symptoms of 
thrombosis are present. When, after removing a necrotic area of the 
bony covering of the sinus, should the sinus wall at one or more points 
present necrotic or sloughing spots and much epidural pus instead of 
the smooth, slightly shining blue surface of a normal sinus wall, then 
there is a strong probability that the infection has already invaded the 
blood-current within. Palpation of the sinus wall is an uncertain 
diagnostic measure, inasmuch as pulsation still may continue after a 
clot of considerable size has formed. If pulsation is absent and the 
pressure sensation is doughy, a thrombus may be expected. 

An occluding thrombus occupying the lateral or sigmoid sinus may 
exist without producing any symptoms referable to the internal jugular 
vein. The local diagnostic signs of thrombosis of the internal jugular 
vein — and they are by no means constant— are pain and tenderness 



LESIONS OF PURULENT OTITIS MEDIA. 357 

extending along the pathway of the vein, the absence of venous bruit, 
swelling of the cervical glands, a cord-like sensation evoked by palpa- 
tion along the thrombosed vein, the fixed position of the patient's head, 
which bends toward the affected side, and finally reflex phenomena 
from compression of regional nerve trunks. 

Reverting to the diagnosis of lateral sinus-thrombosis in general, 
emphasis should be placed upon the importance of early diagnosis, 
inasmuch as the mortality in cases surgically treated is in direct pro- 
portion to the duration and extent of the disease. 

Prognosis. — The prognosis of lateral sinus-thrombosis depends 
upon the duration and extent of the disease, and upon the stage at 
which further progress is checked by surgical interference. The earlier 
the operation the lower the mortality. A localized thrombus of short 
duration, when located in the region of the sigmoid, and therefore 
unaccompanied by involvement of the petrosal sinuses or jugular bulb, 
when operated upon promptly usually results in recovery ; whereas, 
during the later stages, after the thrombus has invaded the contributing 
branches, the torcular, the bulb or jugular vein, the prognosis is less 
favorable and the mortality is high. After metastatic abscesses have 
formed in the lungs, brain, spleen, bowels, etc., the mortality is 
extremely high. 

There is considerable evidence in published reports to warrant the 
opinion that certain individuals possess sufficient resistance to the infec- 
tion to enable them to counteract its effects without the formation of 
thrombi. Once formed, however, a thrombus is prone to suppurate 
and break down, often with a partial or total destruction of the sinus 
wall and subsequent purulent inflammation of the surrounding tissues. 
The author has, during the process of operations upon the mastoid 
process, found the sinus walls enormously thickened and its lumen 
nearly or quite obliterated, and still without any visible clot. 

Treatment. — The treatment of sinus-thrombosis of otitic origin 
is entirely surgical, and for convenience it is herein considered under 
two heads: (a) Cases in which there have been no previous objective 
or subjective symptoms of sinus-thrombosis ; nevertheless, at the time 
of an operation on the mastoid process the infection of the sinus is dis- 
covered, (b) Cases in which the sinus infection either is suspected 
previous to the operation upon the mastoid process, or it develops 
subsequent to the operation. 

In type (a) if a perisinus abscess is discovered during the course 
of a mastoid operation, and if it has existed for a considerable time, the 
portions of the wall thus exposed to the infection will be covered with 
granulations. But if the purulent process has been of shorter duration 
the exposed area of the sinus appears inflamed and thickened without 
the usual granulations. On the other hand an accidental exposure of 
i!i'' sinus during a mastoid operation, when no perisinus abscess exists, 
occa ionally reveals an appearance of the sinus walls which is almost 
identical with those above described. In the absence of the classical 
symptoms of infection or thrombosis of the sinus prior to the operation, 
even though a perisinus abscess is discovered, it is inadvisable to explore 
it either by incision or by puncture unless its walls are necrotic or 



358 THE MIDDLE EAR. 

gangrenous. Even if the surgeon is convinced that a clot is present 
if no symptoms of infective thrombosis have appeared, it is inadvisable 
to interfere surgically with the sinus. The author is firmly convinced 
that non-infective thrombi may develop in the lumen of a venous 
sinus, which eventually become organized into connective tissue. 
To operate upon cases of this type and thereby brave the danger of 
infecting the sterile thrombus is a questionable procedure. 

In every case of perisinus abscess the entire diseased area of sinus 
wall should be exposed to view, but the granulations upon the surface 
of the sinus should not be disturbed, inasmuch as they represent the 
efforts of nature to limit the progress of the infection. Patients in 
whom the operative findings above described are present should remain 
in bed. Meantime both a blood-count and blood-culture (see Chapter 
All) should be made, the temperature taken every two hours, and 
further developments awaited. Should the usual symptoms of infective 
sinus-thrombosis subsequently develop, then the sinus should be 
explored without delay, following the technique hereinafter described. 

In type (&), namely, those in which sinus infection or thrombosis 
is suspected prior to the mastoid operation, or in which a sinus-throm- 
bosis develops at some period subsequent to such an operation, the 
operative technique is as follows : In case the mastoid process is still 
intact a preliminary mastoid operation becomes necessary. After ex- 
cavating all diseased areas of bone the visceral (cranial ) table cover- 
ing the sigmoid sinus should be exposed at some point unless a peri- 
sinus abscess has already brought about such an exposure (Fig. 150). 
In any event it is necessary to enlarge the area of exposure by removing 
the osseous covering of the sinus downward to the level of the bulb and 
backward for a considerable distance toward the torcular (Fig. 254). 
In effecting this exposure great care should be exercised not to make 
pressure on the sinus wall or otherwise disturb its contents. Hence 
the removal of the necessary bony covering of the sigmoid calls for the 
skillful manipulation of instruments. The sharp curet and the rongeur 
forceps are the favorite instruments for removing this bone. After a 
small exposure is made, either by means of a chisel or curet, a slender- 
bladed rongeur forceps (Fig. 148), one blade of which is inserted 
between the sinus wall and the opposing blade adjusted upon the 
adjacent bone, is made to cut and lift the bone piece by piece until the 
desired exposure is obtained. During this and all subsequent manipula- 
tions upon the sinus it is well to have an assistant make pressure over 
the corresponding jugular vein in order to arrest any detached blood- 
clots which may flow from the region of the sinus above. 

Having obtained the positive signs and symptoms of sinus-throm- 
bosis, such as a septic temperature, increased leucocytosis, with a high 
polymorphonuclear percentage, bacteremia, nausea and vomiting, the 
lateral sinus should in every instance be explore 1. even though its walls 
may appear normal. In fact the external appearance of the sinus in 
no wise is an invariable guide to a diagnosis of infection within its 
lumen. The sinus wall may appear perfectly normal, palpation may 
not reveal anything of importance, pulsation may be present or absent, 
and still the lateral sinus may harbor a mural clot. In such a case, 



LESIONS OF PURULENT OTITIS MEDIA 



359 



after free exposure of the sinus, the assistant should hold two plugs of 
iodoform gauze, one over the torcular end of the exposure and the 
other over the cardiac end but not in contact with it, in order to be 
prepared to stop hemorrhage as rapidly as possible. 

The surgeon should now make a free incision in the sinus wall to 
the extent of about one inch (Fig. 254). If free hemorrhage results 
the assistant is directed to make pressure by inserting the plug into 
position over the torcular end of the sinus (Fig. 254). Pressure is 
first made on this end for the reason that if the cardiac end of the 




Fig. 254 — The osseous covering (inner cranial table) of^he lateral 
sinus has been excavated from the level of the jugular bulb upward and 
backward toward the torcular. The gauze controlling plugs are inserted 
and a linear incision has been extended through the outer wall of the sinus. 



sinus contains a clot it is not so liable to be forced into the general 
circulation. After controlling the hemorrhage from the torcular end, 
should there be a free return flow from below, then a controlling plug 
should be introduced into the cardiac end (Fig. 254) and meantime 
the plug over the torcular end is removed. In case the hemorrhage 
from the torcular end then recurs after the removal of the pressure 
plug, it may be assumed that the sinus does not contain a clot, barring 
the possibility that a small clot may have escaped with the rush of blood 
from the incision. A careful examination of the interior of that por- 
tion of the sinus which is situated between the two plugs is then made. 
1 1 no clot is found the outer wall of the sinus should be chipped away 
with curved scissors and the plugs left in position. By so doing the 
sinus finally becomes obliterated. On the other hand, if it is found that 



360 



THE MIDDLE EAR. 



after placing the pressure plug in position on the cardiac end of the 
sigmoid sinus and releasing the plug on the torcular end no hemorrhage 
results, it may he assumed that a clot occupies the lumen of the torcular 
end. This retained clot should be drawn out through the incision by 
means of a small ring curet. The clot usually comes out en masse, but 
occasionally it separates and is drawn out piece by piece. It is some- 
times necessary to introduce the curet nearly to the torcular in order 
to succeed in withdrawing the entire clot. Upon the final removal of 
the clot from the torcular end of the lateral sinus a gush of blood 
ensues and a pressure plug must immediately be introduced to control 
it. This completes the surgery which pertains to the treatment of the 
torcular end of the sinus. 

Should an infective thrombus exist in the lower segment of the 
sinus and extend to or beyond the jugular bulb, the evidences of this 
either would be found in a slight return flow or no hemorrhage at all 
from the bulbar end, upon removing the pressure plug- In rare 
instances a clot may be in a state of disintegration and thus become an 
exception to the above rule. 

The clot located in the descending portion of the sigmoid sinus and 
jugular bulb also is removed by the ring curet, which should be manip- 
ulated with great caution owing to the danger which follows when 
fragments of clots escape into the general circulation. 

If the removal of the clot is followed by free return hemorrhage, 
it may be assumed it has not extended below the jugular bulb, and that 
any remnants will be washed into the mastoid wound by the flow from 
the inferior petrosal sinus. Free hemorrhage from the wound in the 
sinus at this stage is corroborative evidence that the entire clot has been 
removed, and that it is unnecessary to resect the internal jugular vein or 
proceed farther. Hence a pressure plug should be inserted below the 
incision in the sinus to control hemorrhage, and, after trimming off its 
outer wall in the manner described in the previous paragraph, the 
usual mastoid dressings should be applied. 

In case no return flow can be obtained after reasonable efforts to 
remove the clot from the region- of the jugular bulb, or should the clot 
be undergoing disintegration, or the patient's previous symptoms 
indicate profound sepsis, then the internal jugular vein should be re- 
sected. The same procedure would also be indicated upon the appear- 
ance of marked tenderness and infiltration along the course of the 
jugular vein, with enlargement of the adjacent cervical glands, or a 
sensation upon palpation of a cord-like infiltration along the vein. 

Technique of Jugular Resection.— In every instance in which lateral 
sinus-thrombosis is suspected the neck of the patient should be anti- 
septically prepared prior to the operation upon the mastoid process, as 
the saving of time is an important element in the combined mastoid 
and jugular resection operations. After determining that the internal 
jugular vein must be resected, its removal should take precedence, and 
manipulation of the sinus should temporarily be abandoned, inasmuch 
as the resection procedure acts as a dam to the escape of fragments of 
broken-down blood-clots from above wdiich otherwise might enter the 
general circulation. 



LESIONS OF PURULENT OTITIS MEDIA. 



361 



Hence the mastoid wound should be lightly packed and covered 
with sterile gauze and the neck exposed for operation. The skin 
incision should extend from one inch below the mastoid tip to the 
insertion of the anterior division of the sternocleidomastoid muscle 
to the clavicle and sternum, and along- the anterior border of 
this muscle. The primary incision should penetrate the skin, the 




Fig. 255. — Resection of the jugular vein. 



superficial fascia and the platysma myoides inward to the external 
layer of the deep fascia. During this incision the external jugular 
vein will be exposed, and to avoid troublesome hemorrhage it 
should lie picked up and tied at two points about one-half inch apart 
and then incised between the two. The deep fascia should be 
picked up along the anterior border of the sternocleidomastoid 
muscle with two pairs of mouse-tooth forceps and incised between 
them, thus exposing the anterior border of this muscle. The latter 
incision should then be extended throughout the long axis of the 
wound. From now on it is much safer to use the handle of the 



362 THE MIDDLE EAR. 

knife and proceed by blunt dissection down to the sheath which 
encloses the internal jugular vein, the carotid artery and the vagus 
nerve. These vessels lie under the anterior border of the sterno- 
cleidomastoid muscle, and the sheath is more easily reached in the 
area which lies below the anterior belly of the omohyoid muscle. 

After exposure of the sheath of the vessels, an opening is made 
and extended in both directions along the course of the vein. The 
internal jugular vein and the common carotid artery now come into 
view, the former occupying the external position ( Fig. 255 ). 

The next step in the operation consists in isolating the vein 
from its surroundings. A double ligature is then passed around it, 
as near to the clavicle as possible, thus to guard against the dangers 
arising from dislodged blood-dots. The vein is then incised 
between the two ligatures and dissected upward beneath the omo- 
hyoid, it being unnecessary in most cases to sacrifice this muscle. 
The various branches of the vein should be ligated and cut at a 
considerable distance from their junctions with the jugular vein, 
as they are encountered (Fig. 255). 

The insertion of these veins into the internal jugular is rather 
irregular, the thyroid branches sometimes entering by separate 
trunks, but usually by a single trunk. The lingual and facial veins 
usually enter by a single trunk, although this arrangement is not 
constant. The dissection of the vein should continue well beyond 
the entrance of the facial branch and as close to the mastoid tip as 
is convenient. Another double ligature should here be applied and 
the vein excised between them (Fig. 255), after which it may be 
lifted from the wound. Care must be exercised while passing the 
ligatures not to include the vagus nerve. Should the glands along 
the course of the vein be enlarged they should be removed. After 
flushing the wound with saline or bichlorid solution, the incision 
in the neck may be closed with sutures and a cigarette drain 
inserted which should extend from the upper end of the wound to 
its lowest portion. Sterile gauze compresses are then applied. 

Returning to the mastoid wound, the temporary packing is 
removed. 

All remaining clots are removed from the sinus, especially from 
the region of the jugular bulb. "While it is impossible to curet the 
bulb without an extensive removal of bone, it usually is possible to 
remove a large portion of the mass and permit the flow from the 
inferior petrosal sinus to flush the balance. Pressure tampons are 
then introduced and the mastoid wound is dressed in the usual 
manner. 

Difficulties of Jugular Resection.— Aside from the difficulties which 
are induced by faulty technique, the operation may be complicated by 
the presence of numerous enlarged and suppurating glands which 
adds greatly to the difficulties of the procedure; or, as the author 
has seen in one case, the vein may be placed in the centre of a 
large abscess cavity with almost total destruction of its wall. 
Furthermore, instead of occupying its usual prominent position it 



LESIONS OF PURULENT OTITIS MEDIA. 363 

may present the appearance of a small cord-like structure and thus 
be difficult to identify. 

After-treatment. — In cases where it is unnecessary to ligate the 
jugular vein, the mastoid dressings together with the pressure 
plugs usually remain in situ for from two to five days, depending 
upon the general condition and temperature variations exhibited 
by the patient. The removal of the plugs at the end of five days is 
not usually followed by a return of hemorrhage, and the subsequent 
dressings are conducted along lines similar to those employed for 
the simple mastoid operation. 

The wound in the neck should be dressed on the second day 
after operation and the cigarette drain partially removed through 
the lower end of the incision. The neck wound should be dressed 
at least every other day and a small portion of the drain removed 
at each dressing until the wound is entirely free. Should the 
sutures in the neck become infected, it becomes necessary to remove 
them and thereafter treat the wound as an open one. But at each 
dressing the edges of the wound should be approximated as closely 
as possible by means of adhesive straps. Following the operation, 
it may be necessary, owing to loss of blood, to employ saline 
enemata and general stimulation. A liberal saline enema should 
be administered upon the completion of the operation in order to 
counteract the shock and loss of blood. 



CHAPTER XXV. 

COMPLICATING LESIONS OF PURULEXT OTITIS MEDIA. 
(INTRACRANIAL COMPLICATIONS.) 

{Continued.) 

OTITIC DISEASES OF THE MENINGES. 
Method of Invasion. 

The dura mater and other meninges are invaded by infections 
of otitic origin, either by the direct or the indirect route. In the 
first or direct variety, which is by far the most usual form of 
involvement, the dura becomes diseased through direct contact 
with the disease in the neighboring temporal bone, the latter having 
gradually succumbed to the infectious process, until some portion 
of its inner (visceral) table has become necrosed and broken down 
with resulting epidural abscess. 

In the indirect type of invasion the most careful examination 
often fails to show any direct communication between the diseased 
bone and the affected meninges. Boenninghaus is of the opinion 
that the indirect method of invasion is one that takes place through 
the small veins which arise in the lining membrane of the pneumatic 
mastoid cells and which anastomose with veins about the dural 
portion of the lateral sinus. 

Regarding the relationship between the otitis media and the 
meningitis in the given instance, we find that the meningitis may 
accompany the middle-ear disease, or it may follow after the disease 
in the middle-ear spaces has entirely subsided. The latter, how- 
ever, is the rarer finding. 

Very rarely, but still to be mentioned, is the finding of a 
meningeal involvement without a suppuration having been present 
at all in the middle ear, Leutert (1896) having seen a diplococcus 
meningitis follow a catarrhal involvement of the middle ear. These 
cases are similar to those in which a purulent mastoiditis takes 
place accompanied simply by a catarrhal involvement of the tym- 
panic cavity, and when there is no actual purulent disease of the 
tympanic cavity present. 

» Pachymeningitis Externa. 

Localized pachymeningitis affecting the parietal layer of the 
dura is the most common of all infections involving the intra- 
cranial tissues as a result of purulent otitis media. It has been 
observed mure frequently in men than in women, and recorded 
histories show that the right side is more often involved than the 
left. As a rule the portion of dura contiguous to the antrum 
tegmen or attic tegmen (Fig. 259) is the site of the disease, although 
(364) 



OTITIC DISEASES OF THE MENINGES. 365 

the necrotic process may approach the dura from other portions of 
the mastoid or petrous portions of the bone, and even the cerebellar 
dura may become the site of the affection. It is quite possible that 
a small external involvement of the dura in otitic cases may remain 
unrecognized, such symptoms as headache, slight rise of tempera- 
ture, etc., being at the time referable to the middle ear. 

Pathology. — The diseased area of dura may be hyperemic only, 
or it may be deep red, covered with granulations or the formation 
of new connective tissue. The visceral surface of the dura is much 
less often involved than the parietal, which is the primary seat of 
the infectious process. 

In cases of purulent otitis media with cholesteatomata which 
have produced absorption and exposure of the dura, we usually find 
the latter of a greenish color and sometimes partly destroyed. 
Accumulations of pus between the dura and the necrosed and 
broken-down bone are designated as extradural abscess. The com- 
munication between the extradural abscess and the diseased middle 
ear may be very small, or it may become entirely occluded. Patho- 
logically, we therefore differentiate an open extradural abscess, 
that is, one freely communicating with the middle-ear spaces, and 
the closed extradural abscess, wherein the fistula is either exceed- 
ingly small or entirely obliterated between the pus accumulation in 
the meninges and the disease in the bone. 

Situation of the Extradural Abscess. — The accumulations of pus 
are more commonly found over the tegmen, usually choosing the 
space slightly in the rear of the tegmen antri ; they also occur in the 
region of the sigmoid sinus, where they are termed perisinus extra-' 
dural abscesses. More rarely extradural abscesses form on the 
posterior side of the temporal pyramid, and still more rarely upon 
the anterior surface of this pyramid. That they sometimes do 
occur in this locality the published reports of Grunert (1897), 
Sheppard (1898), Grunert, Zeroni (1899), Much (1909), and others 
show. The abscesses occurring on the anterior surface of the 
pyramid arise from direct involvement of the veins in the pneumatic 
cells of the tip of the temporal pyramid in acute cases of middle-ear 
suppuration. 

Those which develop on the posterior surface of the pyramid 
result from chronic suppuration of the middle ear, in which the 
labyrinth also is involved. The exact route travelled by the infec- 
tion from the labyrinth to the dura is as yet unsettled. 

Symptoms. — As already stated, in the simpler forms of pachy- 
meningitis externa the symptoms are practically unrecognizable. 
As a rule the diagnosis cannot be made until after complete 
exposure of the dura by the removal of the portions of necrosed 
bone which lay directly upon it. After removing the necrotic 
fragments of the inner (cranial) table the evidences of I lie disease 
will be seen either as a localized inflammatory area of dura, or the 
exposed dural surface will be covered with granulations. The latter 
probably develop somewhat later, and they serve as protective 
barriers to the further progress *>\ the infective process. The 



366 THE MIDDLE EAR. 

symptoms of pain and fever are neither characteristic nor to be 
differentiated from those of the accompanying pilrulent otitis and 
mastoiditis. 

The diagnosis, therefore, is based upon the above-described ap- 
pearance of the dura as exposed during the progress of a mastoid 
operation. 

The prognosis is favorable when no extension of the disease 
occurs. 

The following remarks upon the treatment of pachymeningitis 
externa are entirely applicable also to extradural abscess. 

Treatment. — Removal of all diseased bone from the mastoid 
cells and exposure of the infected area of dura constitutes the first 
step in the treatment of this affection. The curetment of the bone 
should extend over the entire diseased area of dura. When the 
disease is located in the region of the tegmen the cells of the zygoma 
must be excavated in order to uncover the dura lying over the 
epitympanum. Hence the chief step in the operative treatment 
is the removal of all diseased bone- from the affected dura. Healthy 
granulations upon the dura should not be interfered with, inasmuch 
as they serve to protect the deeper structures. Subsequently, the 
treatment consists in carefully protecting the meningeal surface 
with sterile dressings. The management of the entire wound is 
then carried out as in the case of simple mastoiditis. At each 
subsequent dressing as a precautionary measure, the exposed dural 
surface should be covered with sterile gauze before packing the 
mastoid wound. 

After having discovered the disease during operation it is 
desirable to avoid jars or concussion during the further excavation 
of bone. Even the concussion incident to a slight blow in chiseling 
tends to cause extension of the inflammation beyond the circum- 
scribed area by breaking down the protecting granular adhesions. 
This observation has been made by Urbantschitsch, and but empha- 
sizes my own opinion that in all mastoid operations the chisel never 
should be used except when the bone is not removable by other 
and less dangerous methods. 

Pachymeningitis Interna. 

When the inflammation spreads through the dura to its inner, 
visceral side, there is presented a condition designated pacliymcnin- 
gitis interna. The disease may not progress beyond the limitations of a 
localized infection of the subdural spaces, in which event it remains 
more or less circumscribed in its character; or the process may 
spread until the infection invades the subarachnoidal spaces. The dif- 
fuse purulent inflammatory process which then arises is designated as a 
leptomeningitis. It is not always possible to trace the exact course 
traversed by otitic infection from the middle-ear spaces to the 
subarachnoidal space. Many observers have found the subdural 
space to be free from evidence of disease, even when the infection 
is known to have passed from the external surface of the dura to the 
subarachnoidal spaces. 



OTITIC DISEASES OF THE MENINGES. 367 

Finally, adhesive inflammatory processes occur in some cases 
between the dura and arachnoid, and in the meshes of these 
adhesions small abscesses may form, such abscess formations being 
termed subdural abscess. This is an observation substantiated by 
Heine. 1 

In a small proportion of cases of subdural abscess the brain 
surface forms its inner wall (Kornef). 

Course. — Both the pachymeningitis externa and the pachy- 
meningitis interna may exist for a considerable period of time with- 
out producing serious symptoms or grave pathological lesions. 
The pus accumulation must eventually break into some neighboring 
Structure, and quite commonly these abscesses empty themselves 
into the middle-ear spaces. A perisinus abscess can become evacu- 
ated by draining into the middle ear, by perforating the mastoid 
cortex, or by spreading along the mastoid~emissary vein and thus 
reaching the skull surface. Boenninghaus contends that even an 
extradural abscess, when deeply situated on the anterior pyramidal 
surface, may eventually reach the surface by breaking into the 
pharynx through the foramen lacerum anterior, forming a retro- 
pharyngeal abscess. These modes of evacuation are, however, not 
the common course of the abscess. More frequently, after the 
lapse of time, the abscesses infect the contents of the cranium, pro- 
ducing either diffuse meningitis or brain abscess. 

The treatment of subdural abscess is essentially surgical, the 
requirements being the exposure and opening of the dura for the 
purpose of evacuating the diseased products, and also if possible 
to prevent the development of purulent otitic leptomeningitis. 



Otitic Leptomeningitis. 

Invasion. — The invasion of the meninges by infection from the 
middle ear takes place either in a direct manner by contact with the 
localized area of diseased dura or through a sinus-thrombosis ; or, 
the infection may reach the meninges by way of the veins or lymph 
channels. Regarding the latter mode of invasion it is the opinion 
of many observers that the infection traverses the lymph spaces 
which surround the nerves and arteries, and thus directly estab- 
lishes communication between the middle ear and the subarach- 
noidal lymph spaces. 

Pathology. — We classify otitic meningitis as follows, according 
to Boenninghaus : — 

(Meningitis serosa maligna; 
Meningitis purulenta; 
. Meningitis serosa benigna. 

Of these forms meningitis purulenta is by far the most 
common. In this type of meningitis accumulations of pus are to 
be found in the subarachnoidal lymph spaces, in the interstices of 



Operationen am Ohr, 1904. 



368 THE MIDDLE EAR. 

the brain convolutions, in the spinal canal, and, finally, in the ven- 
tricles nt" the brain. It is contended that the brain substance itself 
is often involved in the purulent process (Ziemmssen and Hess, 
1866). Meningitis serosa benigna and maligna are less well known 
pathologic forms of meningitis. From both the pathologic and the 
clinical standpoint the purulent type of meningitis seems to stand 
in a midway relationship to both. On the one hand, the so-called 
"maligna" type is the most virulent infection of the meninges with 
which we have to deal. According to Dietl, the course of infection 
is so extremely rapid that we rarely find pus accumulations in the 
meninges. The meninges are found to be filled with a serous fluid, 
the brain surface appears softened. This disease according to 
Billroth is significant of general sepsis, and is, per sc, septic in nature* 

The other type of serous meningitis (meningitis serosa 
benigna) is usually designated simply as meningitis serosa. The 
brain substance generally is not involved. The infected area of 
brain substance seems to be sharply circumscribed. When death 
does occur the end seems to be due to a compression of the brain 
by the excessive serous exudate. 

An exact knowledge of the pathologic condition present in 
these lesions determines the surgical therapeusis indicated. From 
Boenninghaus's work in 1897 the following facts regarding the 
lesions are obtained : — 

The diseased process in meningitis serosa benigna begins on 
the outer surface of the brain, usually at the convexity, or at the 
base, taking the form of a meningitis serosa externa, and spreads 
eventually through the lymph channels in the ventricular space to 
form a meningitis serosa interna seroventricularis. The ventricles 
become distended with exudate; the natural communications be- 
tween them become closed by pressure ; the brain surface becomes 
compressed between the fluid on the outside and that within the 
ventricles, and finally death results, as already mentioned, from 
pressure on the brain substance. Pathologically, the picture pre- 
sented is that of hydrocephalus internus and edema cerebri. 

Course. — Because the course, symptomatology and pathology, 
are similar in these conditions, we will consider them together when 
discussing these characteristics of the various forms of otitic 
meningitis. 

The course of otitic meningitis varies with the type of infection 
in the meninges. When dealing with the fulminating type 
severe symptoms of meningeal involvement appear at an early 
stage and often cause death in a few days. These cases usually die 
before a definite diagnosis is made clinically, and but few autopsies 
are recorded of this condition. 

It is a mooted question whether or not a meningitis purulenta 
has sufficient time to proceed to the fatal outcome in this type of 
the disease. The more common course of the disease shows a 
symptom-complex which develops within the course of a week. 
Death usually ensues during the second week, but may be delayed 
until the fourth week. Heine finds this form of purulent meningitis 



OTITIC DISEASES OF THE MENINGES. 369 

is the common complication to both acute and chronic middle-ear 
suppuration. 

There is another type which runs a longer course before death 
supervenes. It usually complicates chronic middle-ear suppuration 
with labyrinthine involvement. There may be remissions in the 
symptoms, and Briezer states that intervals of months and years 
have been observed in these cases. Finally, an attack comes on 
which terminates in death. 

The course of the disease when recovery takes place is some- 
what different. Either because of operative intervention, or spon- 
taneously, all the symptoms disappear. 

Symptoms. — The classical symptoms of otitic leptomeningitis 
are headache, fever and loss of consciousness. Vomiting is fre- 
quently present; spinal rigidity is generally present late in the 
disease (Heine, Schulze). 

In detail, the symptoms which may be observed during an 
attack of leptomeningitis are headache, disturbed mentality, 
aphasia, delirium, loss of consciousness, spinal rigidity, variations 
of pulse rate, nausea and vomiting, extreme sensitiveness to noise, 
and photophobia, unequal pupils with diplopia, choked disk and 
retracted abdomen. Leucocytosis is sometimes present; not, how- 
ever, constant. The list of symptoms above enumerated are rarely, 
if ever, all present in any individual case. The most common of all 
the symptoms is headache, which comes on at the very commence- 
ment of the disease and persists during the entire course. It is of a 
neuralgic type and is usually diffuse. There is usually a moderate 
daily rise in temperature, which, during the first few days, is often 
difficult to differentiate from that of typhoid fever in that the curve 
rises in the afternoon and evening to fall several degrees during the 
morning hours, rarely, however, to normal. During the periods of 
high temperature the headache is more severe, with extreme rest- 
lessness, often rigidity of the neck, and photophobia. 

Diagnosis. — The diagnosis of diffuse leptomeningitis in typical 
cases wherein there is a history of persistent diffuse headache, rise 
of temperature followed by photophobia, rigidity of the neck, 
delirium, and, finally, unconsciousness, is not difficult. In atypical 
cases it becomes necessary to resort to lumbar puncture in order to 
determine the nature of the disease. The symptoms of pachy- 
meningitis interna are quite similar but less profound. Lepto- 
meningitis, when complicating purulent labyrinthitis, presents a 
series of complicating symptoms referable to the labyrinthine 
involvement ; hence, the diagnosis is more difficult to render. 

In all doubtful cases lumbar puncture (see page 69) offers the 
best aid toward clearing up the diagnosis. Concerning the diag- 
nostic value of lumbar puncture there are many conflicting 
opinions, and a voluminous literature is extant both on the findings 
and on the results of these findings when compared with the findings 
from autopsy reports. One salient feature, however, stands ou1 from 
all these reports, viz., if the spinal fluid as drawn from the spinal 
column is cloudy and contains polynuclcar leucocytes, or is found 



370 THE MIDDLE EAR. 

to be clear with a tendency to coagulate, these symptoms may be 
interpreted as definite evidence that the patient is suffering from 
meningitis, because normal spinal fluid is as clear as distilled water, 
contains few it any leucocytes, and when the latter are present they 
are of the mononuclear variety, and, finally, the normal fluid does 
not coagulate. 

The absence of bacteria in the spinal fluid does not preclude 
meningeal invasion; neither does lumbar puncture positively dif- 
ferentiate between purulent and serous meningitis. This form of 
meningitis is entirely separate and distinct from epidemic cere- 
brospinal meningitis, mention of which is made in Chapter XXXII. 

The mortality from otitic leptomeningitis: formerly a recovery 
was a rare exception, but with the advent of a definite surgical 
treatment and a gradually improving technique recoveries are more 
common. 

Prognosis. — Cases have been reported wherein the lumbar 
puncture gave clouded cerebrospinal fluid, containing either strep- 
tococci, pneumococci, or staphylococci, and still they have yielded 
to surgical treatment. In 1906 Hasslauer gathered 14 recoveries 
from literature; MacEwen claimed 6 recoveries out of 12 cases 
operated upon. Successful cases also have been reported by 
Korner, McKernon, Held, Kopetzky and others. 

Therapy. — The treatment is surgical and consists of drainage 
of the meninges and repeated lumbar punctures (see Chapter VI] f. 

Operation on the Meninges. — The steps of the operation are as 
follows : As a preliminary measure the mastoid cells together with 
all areas of bone contiguous to the middle ear should be explored 
and every vestige of diseased bone eradicated. Following this pro- 
cedure the dura should be explored at the point decided upon as the 
most available for drainage. This is usually the space at and above 
the tegmen (Fig. 256). The incisions are then made for the purpose 
of establishing drainage of the accumulated and diseased cerebro- 
spinal fluid. Furthermore, it is proper to incise the brain sub- 
stances if brain abscess is suspected. Ventricular puncture is some- 
times indicated late in the disease in order to relieve the ventricles 
of pressure and of infection. 

Exposure of the Dura. — It is essential that the dura be exposed 
over a sufficient area to afford ample working room. Occasionally 
the dura is diseased at the point of entry of the infection. Again, 
the dissection and removal of necrosis of the tegmen antri or the 
tegmen tympani or tegmen cellulae often reveal the route followed 
by the purulent invasion, and at the same time makes the most 
favorable site for incising the dura, for the purpose of relieving the 
intracranial pressure by drainage. 

The quantity of fluid which escapes depends upon the location 
of the incisions and the degree of intradural pressure at the time the 
opening is made. 

When the posterior cranial fossa is opened a large quantity 
of fluid usually escapes. A single incision through the dura, 
whether cerebral or cerebellar, of sufficient length to permit free 



OTITIC DISEASES OF THE MENINGES. 



371 



drainage is liable to take the form of a gaping wound, and in conse- 
quence there is considerable loss of brain substance. Therefore, 
we advocate a series of short parallel incisions (Fig. 256) into and 
through the dura. These incisions, being shorter, prevent both the 
loss of brain tissue and subsequent brain hernia, and at the same 
time afford ample drainage. 

Drainage of the cerebral cavity is accomplished by two ap- 
proved methods. 1. By removing the tegmen together with a 
segment of the squamous portion of the temporal bone of sufficient 
size to expose an ample surface of the dura over the temporo- 
sphenoidal lobe to permit the necessary incisions (Figs. 150 and 256). 



Fig. 256. — Showin 




the method advised for 
the purpose of drainage. 



lg the dura for 



2. By trephining through the lateral cranial wall about 1% inches 
above the upper margin of the osseous external auditory canal wall 
(Fig. 257). Opinions are divided as to the preference of these two 
sites. 

The first-mentioned method is favored by the author, inasmuch 
as the exposure of the dura is quickly and easily attained by extend- 
ing the mastoid bone wound upward to the level of the temporo- 
sphenoidal lobe, where the exposure is to commence, then, by remov- 
ing the tegmen and a segment of the squamous portion with 
cutting rongeur forceps, the necessary area becomes exposed and 
ready for the incisions to be made. Furthermore, on account of 
the incisions being made in a more dependent portion of the dura, 
the drainage is be1 ter. 

The trephine operation is made by extending the mastoid inci- 
sion in an upward direction in a line perpendicular to the external 
auditory canal, then retracting: the soft tissues so that a button of 



372 



THE Minni.K EAR. 



bone may be trephined at the point above named, or the soft tissues 
may be incised in the form of a flap. 

An oval flap is available for the purpose of approaching the 
meninges above the level of the linea temporalis, either for the 
purpose of draining the meninges or for evacuating a temporo- 
sphenoidal abscess. The method is as follows: The flap is cut out 
with the concha as its base (Fig. 258) (Barnhill). The incision 

is circular and carried down 
to the bone, and after separa- 
tion is turned downward 
and forward over the pinna. 
The skull is then opened 
with a trephine of }i inch 
diameter, at a point located 
l'l inches above Reid's base 
line, and on a perpendicu- 
lar raised from the exter- 
nal auditory meatus. The 
button of bone, thus removed, 
is placed in normal salt solu- 
tion during the subsequent 
procedures in order to main- 
tain its availability for re- 
placement in case the wound 
is closed immediately. 

The dura, thus exposed, 
is examined and incised, 
and where necessarv the 
brain itself explored. Ven- 
tricular puncture may also 
be performed through this 
opening. 

Gauze drains are now 
placed in the dural cavity 
(in the brain itself if condi- 
tions present demand it), 
and the wound in the menin- 
ges dressed separately from 
the mastoid wound. 

Occasionally, where a 
skin ilap lias been cut, it 
may be replaced and sutured 
immediately after the meningeal surgery is finished, thus consti- 
tuting a modified decompression operation. In the majority of 
cases, however, those reacting promptly, il is found that the flaps 
can be replaced at the end of from ten to fifteen daws. 

When the lesion is in the cerebellar meninges and is verv 
extensive, it is sometimes of advantage to open the skull, by means 
of trephine in the area posterior to the mastoid wound and the 
sigmoid sinus. 




Fig. 257. — The trephine operation upon 
the tempi >n '.sphenoidal lobe. The soft 
tissues are incised by extending the 
primary mastoid incision upward snfii- 
ciently to permit the employment of the 
trephine. 



OTITIC DISEASES OF THE MENINGES. 



373 



The bone is exposed by carrying the incision backward from 
the mastoid opening through the soft parts, thus exposing the 
desired area of bone. The periosteum is then retracted, the wound 
lips turned upward and downward respectively, and held apart by 
retractors. Then, by em- 
ploying- either a circular 
saw or a small gouge or 
a strong cutting rongeur 
forceps, a section of the 
occipital bone of suffi- 
cient size to expose ample 
surface of dura for subse- 
quent incisions and drain- 
age is removed. 

The after-treatment 
of the mastoid wound is 
continued as if no com- 
plication had ensued. 

Result of Operative 
Interference of the Menin- 
ges.— The successful cases 
recently published have 
established the fact that 
meningeal drainage will 
save many of these cases 
which otherwise would 
terminate fatally. 

From the case re- 
ports above mentioned 
we can say that, in the 
present state of our knowl- 
edge, the purulent dis- 
eases of the meninges 
are amenable to surgical 
treatment; more espe- 
cially is this true when 
the route of intracranial 

invasion is through the tegmen or the inner table of the mastoid. 
When the disease spreads through the labyrinth the results are not 
so good, unless the disease in the labyrinth is first eradicated. 

Finally, it is the opinion of the author that, even in apparently 
hopeless cases, surgical intervention is justified on the ground that 
the evacuation of accumulated pus from the intradural spaces, and, 
eventually, from the ventricles, together with the relief of tension 
offered by lumbar puncture, will occasionally result in the recovery 
of cases which otherwise would terminate fatally. 




258. — Circular flap over 
the purpose of trephinin 



the squama for 
j the skull. 



CHAPTER X.W'I. 

COMPLICATING LESIONS OF PURULENT OTITIS MEDIA 

(INTRACRANIAL Ci IMPLICATIONS.) 

{Continued.) 



BRAIN ABSCESS OF OTITIC ORIGIN. 

Etiology. — Abscesses in the brain, when of otitic origin, are the 
result of an invasion into the brain substance by infection which has 
traversed the intervening tissues from the middle-ear spaces ( Fig. 259 ). 




Fig. 259. — Section of the temporal bone in which the thinness of the 
inner (cranial) table and the region of the tegmen is depicted. (Author's 
specimen. ) 

The granulations which spring up from the surrounding surface of the 
brain finally form adhesions around the locality infected, which act as 
a retaining wall or partition. The collection of pus usually forms in 
the subarachnoidal space, from which the arteries, veins and lymphatics 
which enter the brain surface become the carriers of the infection. 

Incidentally, these arteries and veins, by becoming thrombotic 
while carrying the invading organism, fail to give further blood-supply 
to the corresponding sections of brain tissue; hence the parts of the 
brain supplied by these vessels become gangrenous, according to Prey- 
sing, who designated the lesion from the pathological standpoint as 
being "encephalitis gangrenosa." On the other hand, destruction of 
the brain substance may go on much more slowly, and a condition 
described by Boenninghaus as "encephalitis purulenta" may ensue, 
(374) 



-OTITIC BRAIN ABSCESS. 



375 



Intracranial abscesses are almost invariably the result of chronic 
middle-ear suppuration. The suppuration in the brain, according to 
Korner and others, is usually in close juxtaposition to the disease in the 
temporal bone. 

Intracranial abscesses occur mostly between the ages of 10 and 30 
years. Hunter Tod found in 100 cases of intracranial abscesses among 
children under 10 years of age that the temporosphenoidal abscesses 
occurred in 87 per cent, and the cerebellar abscess only in 13 per cent, 
of cases. Among adults^ on the other hand, he reports that the cere- 
bral abscess occurred in 65 per cent, and the cerebellar in 35 per cent, 
of cases. Cerebral and cerebellar abscesses occurring together were 
found only in 5 per cent, of cases. 

Intracranial abscesses may be single or multiple. Multiple 
abscesses are rare and generally occur in cases of pyemia. The 




Fig. 260. — Retouched photograph of encapsulated brain abscess. 
Natural size. The cavity of the abscess has been laid open by removing 
a portion of the outer part of the wall. The size of the abscess cavity is 
shown and the thickness of the abscess wall. (Harris P. Moshcr, with 
permission.) 



abscesses may either be encapsulated (Fig. 260) or may not have 
any retaining wall. The walls of encapsulated abscesses are oval and 
regular or irregular and indefinite. The chronic type of abscess 
usually presents a distinct capsule with walls of varying thickness. 
Otitic necrosis of the temporal bone, when located in the antrum 
tegmcn or the tympanic tegmen, tends to cause abscesses in the 
temporosphenoidal lobe, the most common site, while necrosis in 
the posterior group of mastoid cells and in the labyrinth tends to 
produce cerebellar abscess. The cerebellar abscess complicating laby- 
rinthine suppuration usually is found located at or near the internal 
auditory meatus. 

Pathology. — The majority of intracranial abscesses are of the 
encapsulated variety, the walls of which are primarily granulations. 
According to Ziegler, the granulations gradually become indurated and 
changed into thick, cicatricial tissue, the latter retaining a lining of 
granulations. The walls surrounding an encapsulated brain abscess 



376 



THE MIDDLE EAR. 



sometimes reach a thickness of three-eighths of an inch (Fig. 260) and 
the thickness of the walls hears some relation to the duration of the 
abscess. 

The unencapsulated abscesses usually contain a thin, very foul 
smelling pus, mixed with broken-down brain substance. It is quite 
common to find both varieties in the same patient (Fig. 261), the 
unencapsulated abscess being the result of rupture of the wall of the 
neighboring encapsulated abscess, or from a re-invasion of infection 
from the temporal bone. 




Unencapsulated abscess. Encapsulated abscess. 

Fig. 261. — Brain showing the lesion produced by an abscess in the 
temporosphenoidal lobe. In this case both an encapsulated and an unen- 
capsulated abscess were present. The encapsulated abscess lay over the 
roof of the middle ear; the unencapsulated abscess over the roof of the 
mastoid antrum. (Harris P. Mosher, with permission.) 

The brain substance is but slightly affected in the case of the 
encapsulated abscess, while in the unencapsulated variety there is a 
destruction of brain substance of varying degree, usually to a con- 
siderable extent, and often the entire hemisphere is softened and 
swollen and punctured by hemorrhagic points. ( P.oenninghaus.) 

Symptoms and Course. — The course followed by brain ab- 
scesses has been divided into four stages (MacEwen classifies the symp- 
toms in three stages) in order to facilitate the study of the clinical 
signs. 



OTITIC BRAIN ABSCESS. 377 

(a) The Initial Stage. — This stage marks the course often fol- 
lowed by chronic abscesses and rarely by acute abscesses, in which the 
symptoms are quite definite but not sufficiently severe to arouse sus- 
picion of the real condition. The symptoms consist of some rise of 
temperature, moderate or severe headache and vomiting. These 
symptoms are of a short period of duration and usually arouse no 
suspicion of meningeal infection. The symptoms of the initial stage 
are more severe and the disease runs a more rapid course when a 
sudden cessation of the otorrhea immediately antedates the appear- 
ance of the symptoms of brain abscess. 

(b) The Latent Stage. — This is the period where, in a very 
considerable portion of brain abscesses, there are no very definite 
symptoms. The patient attends to his usual occupation and at most 
complains only of moderate headache or intracranial pressure upon 
prolonged exertion of body or mind. When the abscess remains intact 
within its capsule and with no increase in size, no other symptoms may 
appear for months. 

One of the author's cases of this type serves to illustrate the latent 
period. X, male, student, about 19 years of age. A clinic patient 
at the New York Post-graduate Hospital. He was of athletic build, 
nearly 6 feet in height, and weighed 190 pounds. For several years 
he had had a profuse discharge of pus from his ears but complained 
of no other symptoms. He received the usual local treatment for a 
period of three months without signs of cessation of the discharge, in 
the meantime pursuing his studies in the High School. The pus was 
thick, creamy and malodorous. The granulations did not protrude 
through the perforations in the drumhead. At no time during the 
three months of tri-weekly local treatment at the clinic did he complain 
of headache or any other symptoms of pain or discomfort, although he 
did seem anxious to be relieved of the offensive discharge. He was 
finally advised to submit to the radical mastoid operation. 

Upon admission to the hospital his temperature was normal, pulse 
78, and otherwise his condition was good. The operation revealed 
extensive necrosis of the tegmen. Upon removing the softened 
tympanic tegmen, a large encapsulated temporosphenoidal abscess was 
discovered and evacuated. A day or two subsequent to the operation, 
upon questioning him in detail concerning his previous symptoms, it 
was ascertained that for four or five months he had complained of 
moderately severe headache after several hours of close application in 
the preparation of his lessons, aside from which no other sign of brain 
lesion had been experienced. 

Whenever the disease progresses from any cause the headache 
becomes severe and more or less localized upon the diseased side. 
Occasionally the pain becomes intense at the site of the pus collection, 
In cases of cerebellar abscess the patient often complains during the 
early stage of frontal as well as of occipital headache, 

Korner, Boenninghaus and others emphasize die significance of 
pain, more or less localized at the site of the abscess, upon percussion 
of the head. They hold this to he a sign of great importance. In 
progressive brain abscess the patient at this stage begins to feel ill, to, 



378 THE MIDDLE EAR. 

he unable to work, or to endure mental strain. 1 le experiences periods 
of general depression, alternating with states of excitement. Loss of 
appetite and loss of weight ensue and he becomes pale and in general 
presents the evidence of the prodromal period of a severe illness. At- 
tacks of nausea may appear, the tongue becomes coated, and vertigo 
may occur. Usually there is moderate acceleration of the pulse rate and 
a slight rise in temperature. Finally, to these clinical signs there are 
added distinct symptoms referable to the brain, upon the appearance of 
which the chief stage begins. 

(r ) The Manifest Stage. — During this stage, because of the activ- 
ity and growth of the lesion, it presents positive evidences of its exist- 
ence through two groups of symptoms, divided for convenience into a 
group of general symptoms and into a group of symptoms which are 
the result of intracranial pressure. 

The general symptoms pertain to septic absorption. The symp- 
toms depicted above as moderate during the latent period of the disease 
now become unduly severe. The signs of intracranial pressure are 
headache, which may be general or localized, and vomiting which occurs 
without relationship to the partaking of food. Other pressure symp- 
toms are induced by the encroachment of the lesion upon neighboring 
areas of the brain and upon the various cranial nerves. Of the latter 
optic neuritis is an important sign. (Hunter Tod.) It usually affects 
both eyes, although more marked upon the affected side. As the intra- 
cranial pressure increases the temperature falls below normal and rarely 
rises above normal, the pulse becomes slow and bounding, ranging from 
50 to 60 per minute, and the respirations are slow and regular. 

Impairment of mentality now appears and is marked by the various 
forms of aphasia. There is marked impairment of appetite, constipa- 
tion is the rule, and emaciation and prostration ensue. 

The later symptoms of mental impairment are periods of apathy 
and semisomnolence, alternating with periods of intense excitability and 
even delirium, the latter gradually being superseded by drowsiness and 
a tendency to curl up in bed with the extremities flexed. 

When the cerebellum is the seat of the abscess, the patient's gait 
is often characteristic (cerebellar ataxia). There may also be spon- 
taneous nystagmus often directed to the side of the lesion. When the 
cerebellar abscess complicates a necrosed labyrinth this nystagmus, i.e., 
directed to the side of the dead labyrinth, is extremely suggestive of 
cerebellar lesion. 

The pressure on the cranial nerves results in both sensory and 
motor paralysis, depending upon the individual nerves that are en- 
croached upon by the lesion. Oculomotor paralysis (mydriasis ptosis), 
facial paralysis, abducens paralysis, etc. Rigidity of the neck is a late 
symptom of cerebellar abscess. 

(d) The Terminal Stae/e. — Having reached this stage, brain ab- 
scesses, unless relieved, terminate in death. Spontaneous recoveries 
exceptionally occur through rupture of the abscess into the middle-ear 
spaces. Otherwise, surgical interference is the only remaining means 
for saving life. In temporosphcnoidal abscesses, when the terminal 
stage progresses, death usually occurs from increased intracranial pres- 

jradual paralysis of the cerebral func- 



OTITIC BRAIN ABSCESS. 379 

tions. The cerebellar abscess terminates by exerting pressure on the 
respiratory centres, the respirations at first becoming very irregular, 
often of a Cheyne- Stokes character. Again, death may occur suddenly 
by cessation of respiration. Very often death is hastened by the 
rupture of the abscess into a neighboring ventricle, or to intercurrent 
involvement of the meninges, the latter complication being accompanied 
by high temperature, rapid pulse, vomiting, spasms or convulsions. 

Conclusions. — The tendency to encapsulation as a part of the 
history of brain abscesses, especially when the temporosphenoidal lobe 
is involved, probabhy accounts for the comparatively large number of 
cases which seem to go on almost indefinitely without causing serious 
symptoms. In all such cases there undoubtedly has been a period during 
which the patient has suffered from headache, with possibly vomiting 
and temperature variations, but not of sufficient severity to point to the 
actual intracranial disease. Consequently, as the abscess gradually has 
become encapsulated the more acute symptoms have subsided and the 
brain has accommodated itself to the newer condition with a period of 
apparent remission from the severe symptoms. Tain is the most promi- 
nent and persistent symptom of abscess of the brain. 

A sudden cessation of chronic otorrhea usually proves to be an un- 
favorable symptom, inasmuch as it becomes an indication that the tide 
of the pus flow has turned into the meninges, where the infection imme- 
diately induces one of the serious forms of intracranial complications. 
Spontaneous recovery occasionally occurs in the temporosphenoidal ab- 
scesses which are encapsulated throughout, with the exception of a 
minute aperture, which communicates with the necrosed area of the teg- 
men, through which a continuous leakage takes place into the middle- 
ear spaces. 

Abscesses involving the temporosphenoidal lobe — and these 
are by far the most common of those arising from purulent otitis media 
■ — may exist without the manifestation of local symptoms. Cerebellar 
abscess is sometimes associated with or the result of sigmoid sinus- 
thrombosis. The author has reported one such case in which the ab- 
scess in the cerebellum opened spontaneously through the inner (vis- 
ceral) wall of the sinus, from which a large blood-clot had been 
removed a few days previously. The opening was therefore enlarged 
and drained without further surgical procedure. 

Duration. — The duration of brain abscess varies, and depends 
upon the site, size and whether it becomes encapsulated. The disease 
generally runs its course in from two to three weeks, hut it may remain 
latent a year or more.. Generally speaking, the average duration is from 
one to three months. 

Prognosis. — Barring the small proportion of spontaneous re- 
coveries above described, brain abscesses terminate* fatally unless 
relieved by surgical operation. For statistics see Results of ( >pera- 
tion. The results upon life are more favorable when the operation 
is performed during the earlier stages of the disease, before the 
advent of meningeal infection, extensive encephalitis, or the group 
of symptoms which are attributable t<> intracranial pressure. From the 
literature obtainable at this time ii is evidenl thait in cases operated upon 



380 THE MIDDLE EAR. 

about 50 per cent, recover. Cerebellar abscess is proportionately more 
fatal tban is cerebral. 

Treatment. — Exploration of tbe cranial cavity becomes a neces- 
sary procedure as soon as positive symptoms of otitic abscess are 
ascertained, and the indications have been formulated by McKernon as 
follows: — 

1. That a chronic otorrhea is or has been present. 

2. Persistent headaches, general or otherwise. 

3. Restlessness and irritation of temper. 

4. Tenderness of the affected side on percussion. 

5. Nausea, vomiting, vertigo. 

6. An almost persistent low temperature. 

7. A slow pulse, later stupor. Optic neuritis may or may not be 
present, but when present it may aid materially in rendering a diag- 
nosis, as may also aphasia and motor disturbances. 

The treatment of otitic brain abscess is, therefore, essentially 
surgical, and for convenience of description will be defined under the 
general headings : — 

(a) The operative treatment of cerebral abscess; 

( /> ) The operative treatment of cerebellar abscess. 

(a) The Operative Treatment of Otitic Cerebral Abscess. — 
The technique followed in operating on otitic brain abscesses when 
located in the cerebrum must of necessity vary with the seat of the pus 
accumulation. For the purpose of describing the operative technique, 
we will give the steps in the various procedures as employed when the 
abscess is located in the temporosphenoidal lobe, the technique being 
modified to meet the demands when the site of the abscess is elsewhere 
in the cerebrum. 

The old mastoid wound is cleansed and freshened, and its deeper 
parts are lightly packed with sterile gauze. With light taps of the 
chisel an opening is made in the tegmen. When a fistulous 
opening already exists the beak of a rongeur forceps is intro- 
duced between the cranial table and the dura, and the osseous opening 
is thus gradually enlarged, especially in an outward and upward direc- 
tion until a sufficient area of dura is exposed to permit ample space for 
exploring the neighboring brain substance. Having thus exposed the 
dura of the middle cranial fossa to view (Fig. 2f)2), its color is now 
noted and also its tension. When the dura is discolored and bulges into 
the mastoid wound, an abscess in the temporosphenoidal region may 
be suspected. Likewise, from increased tension, pulsations of the 
brain and dura are absent. 

With a small, narrow-bladed knife (Fig. 263) the dura is now 
incised and entered by plunging the knife directly through and then 
into the suspected area of brain substance; or, a crossed incision may 
be made after the manner recommended by Hunter Tod and others. 
The former method is usually ample. The dural flaps are then 
reflected to expose the brain substance. 

The brain is now explored either by inserting a very narrow 
bladed knife, a grooved director, or a pair of sharp-pointed thumb 
forceps. The individuality of the surgeon has much to do with the 



OTITIC BRAIN ABSCESS. 



381 



choice of the instrument employed for exploring the brain, but the 
slender, narrow-bladed knife above described possesses the distinct 
advantage that it produces a clean-cut wound in the brain tissue, the 
smooth tract of which is less liable to absorb infection, and, further- 
more, subsequent healing is quicker. 

The above-described method of opening cerebral abscesses is 
usually efficacious. Authors differ regarding the invariable employ- 




Fig. 262. — Exposure of the dura of the middle cranial fossa by the 
removal of the attic and antrum tegmen. The dotted lines illustrate the 
method of making a succession of incisions into the brain while searching 
for a brain abscess through a single incision through the dura. 

raeht of this method, some contending that better results are obtained 
by trephining the skull in the region of the squamous portion of the 
temporal bone. If, on account of the large size of the abscess cavity, 
or if for any reason it is deemed inadvisable to attempt the drainage 



Fig. 2C>3. — A long slendcr-bladed scalpel for incising the brain substanc 



of the abscess cavity through the tegmen, the latter operation may be 
employed. The incision through the soft tissues may be effected either 
by extending the primary mastoid incision directly upward in a line 
perpendicular to the centre of the external osseous meatus or by means 
oi a circular incision to he extended after the manner already depicted 
in Fig. 258. 

The resulting flap is then turned downward and a button of bone 
trephined from the skull at a point one and one-half inches per- 



382 THE Ml DDLE EAR. 

pendicular to the centre of the osseous external auditory canal. Upon 
its removal the button of bone should be preserved in warm, sterile 
salt solution in case it should be deemed advisable to replace it. The 
search for the abscess cavity through the trephined hone should be 
similar to that already described when exploring the brain through the 
tegmen. In rare instances a counteropening through the squama as 
above described is considered a necessary procedure. In case the 
abscess cavity has already been located through the tegmen, the counter- 
opening should he carried directly toward its known location. 

I laving selected the instrument it is plunged into the brain sub- 
stance in an upward and forward direction (Fig. 262) for about one 
and one-half inches, or until it readies the abscess cavity. The sen- 
sation of having entered a pus cavity in the brain is often felt by the 
operator. Since the abscess is usually situated superficially in the loca- 
tion above described, the knife thrust generally will reach the pus, 
which, in turn, begins to flow out along the shaft of the instrument. 
When the first puncture fails to reveal the abscess the knife is with- 
drawn and another attempt made, thrusting it forward, backward or 
more inward. When the abscess is reached the instrument introduced 
is kept in situ until the pus has drained away, or at least until it has 
been replaced by some more convenient guide to the cavity and, having 
gained access to the abscess cavity, the route through the intervening 
brain tissue should he carefully maintained, and the operator should not 
withdraw an instrument from the cavity without first having used said 
instrument for a guide for the one to follow, and so on until the drain- 
age dressing is finally inserted. 

The primary drainage of the abscess Cavity is an important step in 
the operation. Should an unencapsulated abscess be encountered, it is 
important to remove not only the retained pus, but also to remove 
any necrotic areas of brain tissue. For this reason the incision should 
he sufficiently large to permit the operator to accomplish this object. 
In case a counteropening has been made through the squama it is 
feasible to wash the abscess cavity with a warm normal salt solution, 
providing a temporary drainage tube permits a sufficient outflow to 
circumvent the advent of intracranial pressure from the fluid. 

While the prognosis in the unencapsulated variety of brain abscess 
is less favorable, the healing is more rapid in favorable cases than in 
the encapsulated variety, the advantage being due to the absence of the 
abscess capsule, the latter requiring healing by the granulation process. 

When the abscess is surrounded by retaining walls it is rarely 
necessary to employ the douche for the purpose of evacuation. By 
spreading the lips of the wound it is usually possible to drain the 
abscess cavity and its contents. Any remaining pus may be wiped 
away by means of a cotton-tipped probe. Should it be deemed neces- 
sary to wasli the cavity of its contents two tubes should be introduced 
into its lumen, one for the purpose of conducting the fluid into the 
cavity, and the other for the purpose of evacuating the fluid thus intro- 
duced. The permanent drainage of the cavity is best effected by 
means of the cigarette or gauze drain. Tn introducing the drain it is 
important that it be inserted to the full depth of the abscess cavity. 



OTITIC BRAIN ABSCESS. 383 

When the abscess cavity is of large size better drainage is secured by 
the introduction of a second cigarette drain. During the entire proce- 
dure the brain substance should be handled as little as possible. Care 
should be taken to protect the wound in the dura and other portions of 
the exposed intracranial tissues from infection. This is accom- 
plished by the free use of powdered boric acid dusted over these sur- 
faces and light packing with sterile gauze. The outer end of the 
cigarette drain should be buried in a mass of loose gauze packing, and 
the whole protected by the usual mastoid bandage. 

The outer dressings are then applied. 

(b) Operative Technique of Cerebellar Abscess. — Since the 
cerebellar abscesses may be situated either superficially or deeply, the 
technique is devised to meet these conditions. 

The abscesses which are situated superficially, usually the 
result of disease in the posterior mastoid cells, generally are found 
to lie close to the outer surface of the lateral lobe, just beneath the 
tentorium. 

The deeply situated abscesses, usually the result of internal-ear 
involvement, are mostly found to lie close to the internal auditory 
meatus. With the superficially lying abscesses we generally start 
our exploration from behind the lateral sinus, and with the deeply 
located abscess we begin, in front of the sinus, to explore the 
cerebellum. 

1. Cerebellar Exploration from Behind the Sinus. — The bone 
is removed either by means of trephine or by means of the primary 
mastoid dissection for an area of a square inch behind the sigmoid 
groove, the posterior margin of the sigmoid sinus being the anterior 
and upper boundary of our field of exploration. The dura is incised 
behind the sinus, and the knife puncture is made introducing the 
instrument forward and inward. If the abscess is not tapped 
repeated attempts are made in different directions. 

2. Cerebellar Exploration from in Front of the Sinus. — The bone 
is removed deeply from Trautmann's triangle which lies between 
the anterior border of the sigmoid sinus and the semicircular canals 
(Fig. 241), the latter being the anterior boundary of the explora- 
tion. This exposes a triangular area of dura covering the surface 
of the cerebellum, which lies behind and below the internal auditory 
meatus. 

The placing of the drainage tubes, the counteropening from 
the skull surface, etc., are similar to the steps taken for the cerebral 
abscess. In the case of the cerebellar abscess, when a counter- 
opening from the skull surface is to be made, an osteoplastic flap 
may be tried, but it has no1 generally been a success. 

After-treatment. — Subsequent to an operation which involves 
so serious a procedure as evacuation of an abscess of the brain, it 
becomes imperative to sustain the patient by proper nourishment 
and to relieve the condition of surgical shock'. Concerning the 
latter, it has been the author's experience that no remedy has been 
so efficacious as the introduction of high enemas of normal salt 
solution, repeated at intervals of three or four hours. Patients 



384 THE MIDDLE EAR. 

revive quickly under its benign influence, the pulse becomes 
stronger and steadier and the respirations normal. 

It is extremely important that patients should retain the 
reclining position and live in the must quiet manner until all serious 
symptoms have subsided. Mental worry or excitement and physical 
exertion tend to disturb the conditions within the brain and are 
prone to excite an extension of the pathological process. It is 
sometimes necessary to administer cardiac stimulants in the form 
of strychnia or whiskey, for a few days. The diet should be bland 
and nourishing, and water should be drunk freely. 

The time for changing the primary dressings is gauged by 
the subsequent symptoms, which if entirely favorable in every 
particular, the inner dressings mav remain undisturbed for a period 
of five or eight days. The outer dressings, after the second day, 
usually become stained from the free discharge from the pus cavity, 
in which event they should be changed. Thereafter the outer, 
dressings may be changed daily. In case a rubber drainage tube 
has been introduced into the abscess cavity, it is advisable to with- 
draw it a short distance at each dressing, in order that the abscess 
cavity may freely granulate without the interference of the tube. 

Cerebral hernia sometimes complicates the healing of the bone 
aperture. "When of small dimensions usually they disappear with- 
out special treatment ; but whenever they do not subside pressure 
should be applied by means of a series of gauze pads so arranged 
that pressure will be exerted upon the protruding mass when the 
mastoid bandage is snugly applied. Whenever the protruding 
mass, which mostly is made up of granulations, is intractable, it 
should be excised with the scalpel or scissors. • 

Results of Operation. — Immediate effects are apparent upon 
the successful evacuation of a brain abscess. The pulse and the 
temperature either become normal or, after a short period of eleva- 
tion, they gradually drop to the normal. This is especially marked 
where, prior to evacuation, the pulse and the temperature have 
been subnormal. The sensorium promptly clears, and the patient 
emerges from the comatose state. Paralysis, when of short dura- 
lion, speedily disappears, and nourishment is asked for and retained. 
Finally, cerebration becomes alert. 

The results of operation as reported by Macewen show 8 
recoveries in 9 cases of temporosphenoidal abscess. Of cerebellar 
abscess he reports 4 cases, all of which recovered. Korner reports 
66.6 per cent, cures in the cerebellar cases, and 84.6 per cent, cures 
in cerebral cases from those he was able to collect in the literature. 
Finally, Rapke, examining the literature to determine the perma- 
nence of cures thus effected, finds that 40.4 per cent, of the 
recoveries reported remain permanent. 



SECTION IV. 

Diseases of the Perceptive Apparatus and Miscellaneous 
Diseases and Conditions. 



CHAPTER XXVII. 
DISEASES OF THE PERCEPTIVE APPARATUS. 



OTOSCLEROSIS. 

Under our general classification of diseases of the middle ear 
we include a third type, otosclerosis, which we designate as having 
a constitutional basis. It is characterized by progressive deafness 
which is not due either to a catarrhal or a bacterial process. Like- 
wise, it is distinct from disease of the auditory nerve. Its actual 
nature is still somewhat in doubt. The disease was first described 
by L. Katz (1890), and has since been verified microscopically and 
clinically by many observers. (Denker. 1 ) 

Pathology. — The lesion is a spongification of the bone of the 
labyrinthine capsule. The process begins as a change from the 
normal consistency of the bone to that of compact bone. This is 
later replaced rather irregularly by the spongy deposits. The 
spongification takes place particularly in the labyrinthine capsule 
and around the oval window, eventuating in an involvement of the 
annular ligament, and finally in an ankylosis of the footplate of the 
stapes (Fig. 264). 

Etiology. — Boenninghaus questions whether otosclerosis is to 
be regarded as a primary disease in the bone or whether it is a 
secondary affection, the sequela of a pathological change in the 
middle-ear mucosa. 

Formerly it was a general belief among otologists that the 
changes were secondary to changes in the mucous membrane of 
the middle-ear spaces, and according to the observations of Haber- 
man the deposits follow the course of the nutrient arteries in the 
bone. Shambough, however, has shown that these arteries from 
the mucosa of the middle ear only penetrate to the most externally 
placed layers of bone, and the nutrient arteries from the labyrin- 
thine spaces nourish the deeper bony layers. He further demon- 
strated that the communications between these two systems of 
arterial supply was unimportant (he used the ears of calves for 
his demonstrations, and in these the communications were 
established). 

If the deposits were to follow the route of the arteries they 
should be found located superficially, in the immediate neighbor- 

1 Die Otosclerosa, 1904. 

25 (385) 



386 



DISEASES OF THE PERCEPTIVE APPARATUS. 



hood of the mucosa (Boenninghaus). On the other hand, the 
observations of Politzer and Siebenmann show that the lesion 
develops in the central part of the capsule, and spreads from 
this locality to the surface. Furthermore, Boenninghaus and other 
observers have found the tympanic cavity to be normal in many of 
these cases, and only relatively few gave evidence of the remains 
of a former active pathological process in the tympanic cavity. 
All these factors tend to strengthen the belief that otosclerosis is 
a primary disease of the labyrinthine capsule. We as yet have 
no positive knowledge of what it is that calls into activity this 
lesion in the bone. Hence it is vain to ascribe the disease to con- 
stitutional causes, chronic rheumatism, scrofula, gout, arterio- 
sclerosis, syphilis, etc. It is to be noted, however, as significant, that 





Fig. 264. — Soongification of 
the labyrinthine capsule (Katz). 
(Loaned by Dr. H. J. Harts.) 



Fig. 265. — Spongincation of the 
labyrinthine capsule (Sieben- 
mann). (Loaned by Dr. H. J. 
Hartz.) 



this reason Siebenmann regards the etiological factor to be 
a postembryonal one, due to elements already present in the 
embryo. He does not regard the disease in any way as an inflam- 
matory process. 

The disease seems to be hereditary in certain families. This 
constitutes at least 52 per cent, of all the cases of otosclerosis 
recorded by Boenninghaus. Bezold places it as occurring in 89 per 
cent, of all cases of hardness of hearing in which both ears are 
attacked simultaneously, and of these 60 per cent, occur in women. 

Relative to all ear diseases otosclerosis occurs in about 7 per 
cent, of the cases. 

Course. — The first stage of otosclerosis may be designated the 
latent stage. This lasts just as long as the lesion remains confined 
within the central parts of the bony capsule. 

The manifest stage commences when the spongiflcation reaches 
a functionally active part of the internal ear, usually the footplate 
of the stapes. This seldom occurs before puberty or after forty 
years of age. It is a disease of young adult life. The symptoms 
develop very gradually, although exceptionally a rapid development 
has been noted. Intercurrent constitutional diseases or conditions 
seem to predispose to a more rapid development. Among such 
diseases we may mention pregnancy, lactation, and debilitating 



OTOSCLEROSIS. 387 

diseases, such as typhoid fever. Finally, exposure to intense cold is 
believed to cause a rapid development of the lesion. 

The disease runs a varied course. Sometimes the disease 
becomes exceedingly marked in a very short time, and, on the other 
hand, it may progress slowly for many years, and not become 
seriously marked until it interferes with audition. Usually the 
course seems to be distinctively progressive, until with the advent 
of total fixation of the footplate of the stapes it culminates in a high 
degree of deafness. The disease in some individuals is further 
characterized by periods of quiescence, when no advancement in 
the loss of hearing is appreciable. The above-mentioned periods 
of quiescence vary, in different individuals, from a few months to 
one or two years, after which the symptoms again become active 
and the disease progresses. It is only in very rare instances that 
the lesion involves the labyrinth proper, with resultant . total deaf- 
ness combined with disturbances of equilibrium. 

Symptoms. — Hardness of hearing and tinnitus are the principal 
symptoms. Progressive loss of hearing is a constant subjective 
symptom. This may develop so gradually that it is hardly notice- 
able to the patient at first. Nevertheless, during each year the 
impairment progresses until the human voice and other familiar 
tones are heard with difficulty or become lost entirely. So long as 
the labyrinth remains unaffected, high tones like those of the sing- 
ing voice or musical instruments may be heard. Likewise the 
hearing is often quite good when the patient is in a noisy place 
(paracusis Willisii). 

Tinnitus is severe, persistent and prolonged, and is rarely 
absent at any stage of the disease. In patients who are not 
conscious of having lost some of their hearing faculty, the tinnitus 
will often become so severe that they are led to seek the otologist 
for relief. The tinnitus generally is of a deep tone, but varies 
individually both in tone, character and intensity. In nervous 
subjects severe and prolonged tinnitus often leads to profound 
neurasthenia. The intensity of the tinnitus is no indication of the 
degree of loss of hearing (see Chapter IV). The explanation of 
the tinnitus is still sub judice. In typical cases upon inspection the 
drumhead shows little if any thickening or opacity, it is not 
retracted and the light reflex remains visible. The Eustachian tube 
is patent throughout. Vertigo is rarely present in otosclerosis. 

_ Diagnosis. — There is only one positive objective sign upon 
which a diagnosis may be based, and this according to most 
authorities is not invariably determinable. It is termed the 
"Schwartze symptome" and is characterized by isolated areas of 
hyperemia in the mucosa covering the promontory, as seen through 
an atrophied, transparent drumhead. 

When in a case of chronic, progressive loss of hearing we are 
able to exclude middle-ear inflammation and also labyrinthine 
disease, then the finding of isolated areas of hyperemia on the 
mucosa covering the promontory, as seen through the normal drum- 



388 DISEASES OF THE PERCEPTIVE APPARATUS. 

head, confirms the diagnosis of ankylosis of the stapes — otosclerosis. 
(Boenninghaus.) 

Middle-ear inflammations may be excluded on account of the 
characteristic otoscopic picture and the use of the catheter. Laby- 
rinth diseases are excluded through functional tests of the mobility 
of the stapes (Gelle's test). Disease of the conducting apparatus 
is evidenced by the fork test (prolonged bone conduction), normal 
or only slight loss of the upper notes of the scale, and decided loss 
of the lower notes in the scale, that is, the low-tone limit becomes 
markedly raised. 

Uncomplicated cases of otosclerosis are the most easily diag- 
nosticated. When complicated by other lesions the diagnosis 
becomes a most difficult and sometimes an impossible problem. 
Generally speaking, the bone conduction may be almost normal, 
only slightly shortened, especially for the fork C 2 . It is found 
somewhat lengthened for the C fork — the, upper-tone limits are sharply 
lowered and the lower-tone limit decidedly raised. 

As the disease progresses in the labyrinth proper the symptoms 
from the ankylosed stapes become completely masked, and the hard- 
ness of hearing approaches complete deafness, the upper-tone limit 
gradually becoming lower and lower until the entire scale is lost. 

Between chronic middle-ear catarrh in its advanced stage and 
otosclerosis differentiation is almost impossible. In chronic middle-ear 
catarrh the hearing power is influenced by inflation when continued 
for some time ; in otosclerosis the hearing remains absolutely 
uninfluenced. Finally, in all doubtful cases a family history of 
otosclerosis should be given great weight. 

Prognosis. — So far as arresting the disease is concerned the 
prognosis is very bad. On the other hand, regarding total eventual 
deafness, otosclerosis gives a better prognosis, as it is not usual 
for the spongification to involve the labyrinth structures proper. 

Where the last-named lesion does occur, the prognosis is poor, 
and, although a high degree of deafness will eventually ensue, it 
takes years to develop. 

Treatment. — When a diagnosis of otosclerosis is positive, or 
even when ankylosis of the stapes is definitely established, there is 
but slight hope of influencing the disease by any system of treat- 
ment. When the ankylosis of the stapes is partial but sufficient to 
mechanically impede the propagation of sound impulses, then 
efforts to break up the ankylosis are to be considered in mapping 
out a course of treatment for these patients. 

The simplest way to accomplish this purpose is through car 
massage (see Chapter VIII). A Siegel otoscope attached to a 
pump worked by an electric motor best serves our purpose (motor, 
Fig. 3; Siegel otoscope, Fig. 26). A simpler apparatus is the Del- 
stanche masseur. It acts similarly to the Siegel otoscope and motor 
pump. Its advantage lies in its comparative cheapness. 

Lucae has devised a simple apparatus whereby he attempts 
to break up the ankylosis by water massage. The Lucae pneumo- 
hydromassage is given by means of an instrument which consists 



OTOSCLEROSIS. 389 

of a glass ear speculum somewhat longer than the ordinary 
speculum, so as to fit snugly in the external auditory meatus. 
Usually it is capped with rubber so as to make it watertight in the 
ear canal. At the other end of the "T" there is a diaphragm so 
arranged as to hold the water which is placed in the stem of the 
T-shaped tube. This rubber end fits into another glass tube snugly 
and to this another tube is attached, which is connected with a pump 
worked by an electric motor. The T tube is filled with water. 

The impulse transmitted by the pump goes through the tube 
and impinges upon the rubber diaphragm, where it is taken up by 
the water, and this transmits the impulse to the eardrum and drives 
it inward, acting on the ossicles and moving them. 

Lucae also devised a spring pressure sound for the purpose of 
breaking up ankylosis of the ossicles (Fig. 49). This consists of a 
probe the end of which is fitted to a small cup. The other end is 
attached to a handle, around which a spring works, so that, when 
the cup is placed upon the processus brevis and the instrument 
pressed inward, the spring gives resistance and thus graduates the 
amount of force used. The handle is so constructed that the pres- 
sure can be changed to varying degrees. The use of this instrument 
entails much pain, and requires a skillful operator lest injury to the 
eardrum result. 

Extraction of the stapes has been tried by Kessel and others. 
The operation entails danger, through infection, and is unsuccessful, 
because during the operation the stapes usually fractures and the 
head and its crura come away, leaving the footplate in situ. The 
object of the operation is thus defeated, and, because of the danger 
of an infection of the labyrinthine channels, the operation of 
removing the stapes is no more attempted. 

The results of massage vary. In rare instances some improve- 
ment in hearing is secured and the tinnitus is relieved, at least to 
some extent. One meets cases which are unfavorably influenced 
by the massage treatment. In these the prognosis is bad. Neither 
is local treatment of avail in arresting the advance of the disease. 
The majority of patients suffering from otosclerosis lose courage 
and float around from one otologist to another, or cease treatment 
altogether. Unless warned in season they afford a rich harvest 
for quacks and charlatans. 

Meanwhile, general treatment should be given to the patient 
and his habits and diet should be regulated. All excesses should be 
interdicted, and especially should alcohol and tobacco be debarred. 
Cold-water baths and sea bathing are harmful. The evil effects 
of anemia, plethora, constipation, excessive work and worry should 
be combated. The patient should not wear constricting clothing 
about the neck or anything which raises the blood-pressure in the 
head — pressure at stool, tight corsets, collars, etc. Warm baths 
are recommended, and resort to mountain heights in the summer 
season is beneficial. 

Medicinally, various drugs have been employed. The drug 
which apparently has the most influence in affecting the bone 



390 DISEASES OF THE PERCEPTIVE APPARATUS. 

deposits on the labyrinthine capsule is phosphorus. This was first 
recommended by Siebenmann in 1898. The use of this drug is 
based upon experimental work of Alirva and Stotzner during 
clinical observations upon its effects in cases of rachitis. Sieben- 
mann claims that in 50 per cent, of the cases he at least arrested the 
progress of the disease by using phosphorus. The following 
formula has found favor and is convenient to administer : — 

B Phosphori 0.03 

Olei jecoris aselli 
or 

Olei olivarum q. s. ad 300.0 

M. Sig.: 3ij twice daily. 

It may also be advantageously administered as follows : — 

B Phosphori 0.03 

Olei amygd 30.0 

Gum arab 30.0 

Aqua dest 300.0 

M. et ft. emulsio. 

Sig.: 3ij twice daily. 

The iodin preparations also have been found efficacious for 
relieving tinnitus. Potassium iodid in increasing doses is given. 

All of these medicinal preparations must be continued for long 
periods. 

MISCELLANEOUS LESIONS OF THE PERCEPTIVE 
APPARATUS. 

Hemorrhage and Emboli in the Labyrinth. — Hemorrhage into 
the labyrinth channels occurs occasionally under a variety of condi- 
tions, the most important of which we will briefly discuss. 

Alexander (1903) and also Schwabach (1897) report cases 
of hemorrhage into the labyrinth in leukemia. Besides the blood, a 
large number of lymphocytes are found in the labyrinth. These 
hemorrhages cause compression and result in degeneration of the 
nerve, the ganglion cells and the organ of Corti. 

The labyrinthine symptoms develop either gradually and 
slowly or they develop rapidly and become evident only prior to 
death. 

Habermann (1890) reported a case with labyrinthine hemor- 
rhage, as a complication of pernicious anemia. 

Sugai (1900) and Citelli (1906) observed labyrinthine symp- 
toms and diagnosticated labyrinthine hemorrhage in cases of 
purpura hemorrhagica; while Morf (1897) contends that hemor- 
rhages into the labyrinth accompany both acute and chronic nephritis. 
Boenninghaus, however, believes that the hardness of hearing and the 
other ear symptoms observed in the course of nephritis are the 
direct result of the uremia rather than of hemorrhage into the 
labyrinth. 



MISCELLANEOUS LESIONS, ETC. 391 

Caisson Workers' Disease. — This condition is also classed by 
many as a lesion due to hemorrhage into the labyrinth. 

These workmen labor in chambers wherein air pressure is 
much increased over the ordinary atmospheric pressure. As they 
leave these chambers, and return to the normal air pressure, they 
undergo a series of symptoms known in the trade as ''bends," which 
consist of an apoplectic seizure lasting from a few minutes to 
hours. During this attack they develop the Meniere symptom- 
complex. The dizziness may gradually disappear, but the hardness 
of hearing remains for a much longer time. According to Alt 
(1897), the labyrinthine capillaries are plugged with gas emboli, and 
at spots with extravasations of blood. 

Acoustic Neuritis. — Nerve deafness may originate from any 
conditions which would cause a neuritis in other parts of the body. 

According to Wittmaack (1903), in acoustic neuritis the disease 
is confined almost exclusively to the nervus cochlearis, affecting 
mostly the peripheral neuron, the ganglion spirale, and the hair 
cells of the organ of Corti. 

Regeneration of the nerve is believed to be possible as long as 
the ganglion cells are not destroyed completely. 

Diagnosis. — Absolute diagnosis is not possible, but in some 
it is possible to differentiate acoustic neuritis from other labyrin- 
thine affections. Nerve deafness usually presents no symptoms of 
dizziness and no Meniere symptom-complex. The etiology gives 
additional diagnostic data; the ingestion of toxic substances, 
quinine, salicylate of soda, excessive use of tobacco, etc., tend to 
induce nerve deafness, while meningitis and otitis media purulenta 
are more likely to result in labyrinthine disease. The diagnosis is 
one of elimination. 

Clinically we differentiate two types of acoustic neuritis. The 
first type, due to explosion of cannon or other sudden, loud noises, 
gun fire in military life, etc., and the second type, the more common, 
caused by certain trades like that of boilermakers or other factory 
workers whose ears are continuously exposed to loud noises. 

These cases present distinct loss in bone conduction, and they 
do not hear the whispered voice. 

Pathologically, they are victims of atrophy of the nervus 
cochlearis. 

Finally, cases of nerve deafness may be grouped, according to 
their causative factors, as follows: — 

1. Those caused by poisons. Under this heading are placed 
quinine, salicylate of sodium, tobacco, alcohol, lead poison, phos- 
phorus, etc. 

2. Cases caused by toxins. Bacterial toxins in the blood are 
accountable for most of this group. The toxins of typhoid, typhus, 
tuberculosis, measles, scarlatina, diphtheria and the mumps are 
examples of this group. 

3. Cases caused by constitutional disease. The most important 
in this group are those caused by diabetes. The next most impor- 



392 DISEASES OF THE PERCEPTIVE APPARATUS. 

tant are those caused by syphilis. Finally, the disease may be 
caused by autointoxication (Stucky), or by the rheumatic diathesis. 

Primary Atrophy of the Acoustic Nerve. — This condition is not 
necessarily the result of a prior inflammation of the nerve. It is 
found in old age and in those with premature arteriosclerosis. 

In the cases of senile atrophy neither dizziness nor tinnitus are 
experienced, whereas in the cases of premature arteriosclerosis 
these symptoms are usually present (Stein). 

In cases of tabes (Chapter XXXII), according to Friedrich, 10 per 
cent, suffer from nerve deafness due to degeneration of the nerve. 

The ear symptoms may precede all other signs. The deafness 
is rapidly progressive, and soon other signs of tabes become estab- 
lished and the diagnosis is made. 

Finally all these obscure cases of hardness of hearing should 
be thoroughly examined physically, the status of their arteries 
determined, the blood-pressure estimated, the urine examined, and 
the reflexes particularly looked into, in order to furnish additional 
diagnostic data. 



CHAPTER XXVIII. 
MISCELLANEOUS OTITIC CONDITIONS. 



HYPEREMIA OF THE MENINGES INDUCED BY INFECTION IN 
THE MIDDLE EAR. 

Simple hyperemia of the meninges incited by the pressure of 
pus in the middle ear undoubtedly occurs with comparative fre- 
quency. It is believed that portions of the dura adjacent to the 
middle-ear structures become congested and hyperemic, but, un- 
fortunately, postmortem examinations of this condition are ex- 
tremely rare, inasmuch as recovery usually takes place and the 
hyperemia terminates in resolution. Occasionally the disease 
progresses and the local inflammatory areas result in thickening, 
bony adhesions and even cerebral softening. Unless the primary 
etiological factor is removed the disease may terminate in serous 
meningitis. 

EMBOLI IN THE BRAIN FOLLOWING THROMBI IN 
THE CAROTIDS. 

While thrombosis is more common in the large venous menin- 
geal vessels, arterial emboli of carotid origin are occasionally 
observed. The thrombus as a rule is transmitted into the area 
supplied by the artery of the Sylvian fissure of the same side. 
Korner has reported several of these cases wherein thrombi in the 
carotids had been discovered. 

OTITIC PYEMIA. 

Pyemic infection of the meninges and brain is one of the 
deplorable complications of both acute and chronic purulent otitis 
media. The disease never remains entirely local and extends more 
or less rapidly to other organs of the body. Otitic pyemia occurs 
oftener in connection with chronic than in the acute form of puru- 
lent otitis media, and furthermore it is often confounded with 
purulent meningitis, from which a differential diagnosis is difficult 
to establish. If an absolute diagnosis of otitic pyemia could 
invariably be rendered, then many cases now classed as purulent 
meningitis would properly be classified under the former heading. 

Pyemic infection is believed to migrate chiefly through the 
lymph vessels, but to a lesser degree the infection may be carried 
by blood-vessels through inflammatory exudation of the vascular 
walls and rapid formation of thrombi. When pneumonia bacilli 
prevail in the middle-car discharge a complicating pyemia is more 
prone to ensue, and lateral sinus involvement may or may not be 
present. 

(393) 



394 DISEASES OF THE PERCEPTIVE APPARATUS. 

Metastases in various organs may be produced by tbe bacteria 
which circulate in the blood, when it is the seat of bacteremia. 
Korner differentiates two types of otitic pyemia, one in which it is 
associated with sinus phlebitis, and in the other there is no com- 
plication. The former is more commonly combined with chronic 
purulent otitis media, and the latter with acute purulent otitis 
media by means of absorption of pus from the primary focus in the 
temporal bone. 

Primary otitic pyemia, in acute as well as chronic otorrhea, 
sometimes originates by direct infection through the floor of the 
tympanum. The pathway of infection may be (a) through dehis- 
cences in the tympanic floor; (b) through openings in the floor 
which have resulted from necrosis; (c) through the normal foramina 
in the tympanic floor. The infection in the above-described cases 
invades the dome of the jugular bulb. 

Diagnosis. — The diagnosis is based upon the clinical evidences 
nf sepsis and the presence of bacteria in the blood. 

Prognosis. — The prognosis is grave and unfavorably influenced 
when associated with sinus phlebitis. Timely surgical interference 
influences the prognosis favorably. 

Treatment. — The treatment must first be directed against the 
original pathological focus in the temporal bone, and all diseased 
tissue in this region should be radically extirpated. Occasionally, 
when accompanying acute purulent otitis media, the symptoms will 
rapidly subside after the confined pus has been evacuated by 
paracentesis. If the pyemic manifestations are not arrested as a 
result of this procedure the mastoid process should be surgically 
entered, all diseased tissues removed, and the lateral sinus suffi- 
ciently exposed to admit of proper inspection. Where the sinus 
is found to be diseased or thrombosed it should be operated upon 
after the manner described in Chapter XXIV, page 357. 

Finally,, the vaccine treatment may be given a trial. 

OTITIC SEPTICEMIA. 

Septicemia of otitic origin is characterized by violent symp- 
toms and an extremely rapid course. The prominent symptoms 
are chills, profuse sweating, remittent fever, with irregular respira- 
tive curve, great prostration and delirium. The infection travels 
by way of the lymphatic channels, and, according to Korner, there 
usually is a septic involvement of the retina, heart and kidneys, and 
hemorrhage into the muscular tissues. Metastatic abscesses are 
usually absent. The disease often proves fatal within a few days. 

Diagnosis. — That of general septicemia. 

Prognosis. — Unfavorable. 

Treatment. — The same as for general sepsis. Stimulants and 
attention to the kidneys, bowels and skin. 



MISCELLANEOUS OTITIC CONDITIONS. 395 



DISTURBANCES OF THE HEARING FUNCTION OF 
INTRACRANIAL ORIGIN. 

Acute meningeal inflammations, intracranial, gummatous and 
tubercular deposits have already been referred to (Chapters XXIV, 
XXV, XXVI, XXIX and XXX) as causes of tinnitus, vertigo and 
deafness. Other cerebral causes are those originating either in the 
roots, nuclei or trunk of the auditory nerve. Still more common and 
important are : cerebral hemorrhage, embolism, chronic sclerosis, 
acute and chronic hydrocephalus, and new growths. Severe and 
persistent tinnitus is often a prodromic symptom of an impending 
apoplectic attack, and, when occurring in elderly individuals with 
sclerosed arteries or cardiac diseases, this symptom should be 
looked upon with suspicion. 

DEAF-MUTISM. 

The acquisition of speech is dependent upon audition. In 
congenital deafness, or when the sense of hearing has been lost 
during the first years of life, the individual has been bereft of the 
strongest impetus to the acquirement of speech, and as a result 
it is either never acquired or is progressively lost until the deaf 
child has become a deaf-mute. It is rarely possible to determine 
whether deafness is absolutely congenital or whether the perceptive 
function has been destroyed by disease. 

Etiology. — Deaf-mutism is usually the result of some disease 
of early infancy which has produced either destruction of or severe 
injury to the perceptive mechanism, a condition which may remain 
unnoticed even by parents until long after the usual time when the 
child should commence to interpret sound vibrations. That he- 
redity plays an important role there can be no question, inasmuch as 
statistics clearly show that deaf-mutism is more or less clearly 
influenced by consanguinity in parentage, and to some extent by 
direct transmission, although the children of deaf-mute parentage 
usually are found to possess good hearing. Inherited diseases, like 
syphilis, are believed to possess some indirect influence along this 
line. Intra-uterine disturbances have also been mentioned as 
causative factors. By far the larger percentage, however, of deaf- 
mutism results from those infantile diseases which tend to destroy 
the perceptive function. Among these the acute infectious diseases, 
intracranial inflammations, notably epidemic cerebrospinal menin- 
gitis, adenoid vegetations, inasmuch as they indirectly incite intra- 
tympanic and labyrinthine inflammations — in fact, any inflamma- 
tory condition which tends to affect the sense of hearing in early 
childhood will be found to seriously interfere with the acquisition 
of speech. Tn a considerable percentage of cases the chief causative 
factor is the congenital absence of some portion of the perceptive 
or conductive mechanism, such as meatal atresia, intratympanic 
malformations, occlusions of cither the oval or round window, or 
defect in the trunk or distribution of the auditorv nerve. 



396 DISEASES OF THE PERCEPTIVE APPARATUS. 

Total deafness for all sounds in deaf-mutes is rare, the majority 
exhibiting defective perception for the highest and lowest sounds, 
or a limitation of the auditory field sufficient to materially interfere 
with the acquisition of speech. Often there is an unequal perception 
of individual sounds. It is important to differentiate between the 
actual perception of speech and the intellectual appreciation of the 
spoken word (psychical deafness). 

The first symptom usually observed is that the child is passing 
by the age when articulate speech should develop. At this 
period parents usually make use of other means to determine 
whether the auditory function is present, often submitting the ears 
to examination either by the family physician or the otologist. In 
the more severe cases the failure to respond to questioning, 
together with noticeable failure to give any form of evidence of 
the perception of very loud sounds, gives clear indication of mutism. 
When due to purulent or intracranial inflammations in children 
who have already learned speech, there will be noted a gradual 
loss of vocabulary and finally failure to respond to all sounds. 

Diagnosis. — The diagnosis of mutism must be based upon the 
failure of the individual to acquire speech during that period of life 
when this function may be expected to develop, an age which varies 
considerably. It should be noted that normally the development of 
this sense is often much delayed. A previous history of severe 
aural attacks is of considerable aid in determining the state of the 
perceptive function. Tuning forks, loud jars or noises are also to 
be employed, although in very young children they do not in- 
variably furnish conclusive evidence. Loud clapping of the hands 
just posterior to the occiput by an assistant unseen by the patient 
furnishes valuable evidence, inasmuch as the facial expression will 
usually clearly indicate whether the child has heard or not. In 
children of sufficient age and intelligence the tuning fork and 
Galton whistle should always be employed, inasmuch as aerial and 
bone conduction in mutism will be found partially or wholly 
destroyed. 

Prognosis. — The prognosis is always grave, both for audition 
and the acquisition of speech. Politzer 1 contends that a better 
prognosis may be expected in the congenital cases. 

Treatment. — The treatment is twofold : (a) to overcome the 
deafness, and (b) to develop speech. The former, in addition to 
the required local means, the technique of which is described in the 
chapters relating thereto, includes the treatment of any middle-ear 
lesion which may complicate the deaf-mutism ; meanwhile the 
affections of the nose and nasopharynx, especially diseased adenoid 
tissue, and hypertrophied tonsils should receive appropriate treat- 
ment. The development of speech in these cases is largely edu- 
cational ; methodical hearing exercises are of supreme importance, 
especially when it can be demonstrated that even a small propor- 
tion of the hearing function remains. These may be carried out by 



1 Diseases of the Ear. 



MISCELLANEOUS OTITIC CONDITIONS. 397 

directing the patient's attention to auditory impressions and 
developing his appreciation of spoken words, musical sounds, 
and various noises, much time being given to stimulating and 
strengthening these impressions. The systematic use of hearing 
exercises whenever possible should be carried out by a teacher 
whose training and intelligence, patience and perseverance have 
specially fitted him for this important work. This method should 
not be too soon abandoned, even under discouraging circumstances, 
since the possibility of success exists even in mutes heretofore 
considered hopelessly deaf. Urbantschitsch points out in this con- 
nection that a further development of the auditory sense becomes 
possible as a result of the awakening of the first vestige of hearing. 
Independent exercises with musical sounds or with speaking tubes 
may be conducted by the patients themselves. The early efforts 
are largely expended to overcome the patient's diffidence and 
seeming lack of interest ; hence, it often requires persistent training 
for months, and they do not usually attempt speech until they have 
actually acquired considerable proficiency. The influence exerted 
by methodical hearing exercises upon the hearing sense stimulates 
the individual to further development and lays the foundation for 
appreciative comprehension of auditory impressions. The signs of 
improvement in audition are characterized by a gradual differentia- 
tion of various sound impressions, together with a fuller com- 
prehension of the significance of spoken words. Methodical hear- 
ing exercises should be continued, throughout the period during 
which ordinary sound waves do not suffice to raise the sensation 
of hearing beyond the mere threshold of perception, until the more 
ordinary sounds are perceived and comprehended by the strengthened 
auditory sense. 

The results of the hearing exercises depend upon the character 
and duration of the training, the condition of the function and the 
personal equation of the patient. It cannot be too strongly 
emphasized that individual teaching is practically essential in order 
to procure the best results. When this is impossible mutes should 
be placed in the very best obtainable schools where the same 
methods are carried out, even though with less individual instruc- 
tion. 

In several of the large cities of America, including New York 
City, the school boards have established schools devoted exclusively 
to the education of children with defective hearing. Here they not 
only receive instruction in articulate speech and the acquirement 
of knowledge through books, but are taught the art of manual 
training which fits them for self-support and positions of trust and 
responsibility. 

Lip Reading. — It is well known that the loss of one special 
sense is partially recompensed by added acuteness of those which 
remain. Individuals who are partially deaf invariably watch the 
movements of the lips and facial expression of those who address 
them and arc thus better able to understand conversation. Lip 
reading has, therefore, been placed upon a scientific basis, and is 



398 DISEASES OF THE PERCEPTIVE APPARATUS. 

taught privately and in schools with marked success. The student 
of lip reading succeeds oniv by the most continuous and painstaking 
personal effort, both upon his part and that of the teacher, and 
special individual instruction is imperative. The otologist is 
usually consulted in regard to the employment of instructors, and 
should recommend only those who are capable and free from 
charlatanism. 

THE RELATION OF EAR DISEASES TO LIFE INSURANCE. 

The majority of life-insurance companies refuse to insure appli- 
cants who suffer from purulent otitis, and maize no attempt to 
discriminate as to the variety, extent, character or severity of the 
infectious process. The author has taken considerable pains to 
gather statistics in an attempt to formulate some rules which 
might bear directly upon the question of actual risk to life in the 
various types of aural disease. In a paper published in the Transac- 
tions of the American Laryngological, Rhinological and Otological 
Society, 1903, he states that Schwartze's records show that about 
13 per cent, of all aural diseases are of the chronic purulent variety. 
A study of Guy's Hospital Reports by Pitt 2 shows that, of 9000 
consecutive autopsies at Guy's Hospital, between 1869 and 1887, 
there were 57 cases of death due to aural suppuration, or 1 in every 
158 autopsies. Gruber, 3 in the report of 40,073 autopsies held at 
Vienna General Hospital between 1873 and 1894, says death was due to 
aural suppuration in 232 cases, or 1 in every 173. Poulson, 4 out of 
14,580 autopsies at the hospital in Copenhagen, from 1870 to 1895, 
in 48 cases, or 1 in every 303, says death was due to aural suppuration. 
Barker 5 reports that out of 8028 autopsies in three London hospitals 
death was due to aural diseases in 45, or 1 in every 178. By total- 
ing these figures it will be seen that out of 71,681 autopsies there 
were 382 deaths resulting from aural suppuration, or 1 in every 
187. A comparison of these autopsy reports with the statistics 
covering work done in the treatment of aural diseases in hospitals 
and clinics furnishes considerable valuable information. Birkner 6 
states that out of 33,017 cases of aural diseases of all kinds there were 
104 deaths from the effects of aural suppuration, or 1 in every 17. 
Randall 7 out of 5000 cases of aural disease of all kinds reports 15 
deaths due to middle-ear suppuration, or 1 in every 333. Dench 
found that out of 64,858 cases of aural disease treated at the New 
York Eye and Ear Infirmary there were 218 cases of serious intra- 
cranial complications, or 1 in every 296. Of these there were 20 
cases of cerebral abscess, 46 cases of sinus-thrombosis, 7 of cere- 
bellar abscess, 2 of otitic meningitis, and 119 of epidural abscess. 
It should be noted that these were not all fatal cases. He also 



2 British Medical Journal, 1890, vol. i, p. 643. 

3 Monatsch. fur Ohrenheilkunde, 1896, p. 311. 

4 Archiv fur klin. Chirurgie, vol. lii. Section 2. 

5 Hunterian Lectures, Illustrated Medical News, London, 1889. 

6 Archiv fur Ohrenheilkunde, vol. xx, p. 81. 

7 Transactions of the American Otological Society, vol. v, No. 1, p. 101. 



MISCELLANEOUS OTITIC CONDITIONS. 399 

noted that of the total number there were 4836 of acute purulent 
otitis media, 14,487 of chronic purulent otitis media. Making these 
the basis of calculation, intracranial complications occurred in 1 
out of every 88. 

The author's statistics, based upon the records of the Man- 
hattan Eye and Ear Hospital, show that out of 29,223 cases of 
aural diseases recorded there were 118 cases of serious intracranial 
complications, or 1 in every 248. Of these there were 32 cases of 
involvement of the lateral sinus, 16 of otitic meningitis, 12 of brain 
abscess, and 58 of extradural abscess. Of the total number there 
were 7614 cases of purulent otitis media, of which 2436 were acute 
and 5178 chronic. Making the purulent cases alone the basis of 
calculation, there was 1 serious complication in every 65. Not 
all of these were fatal and many- are restored to health by timely 
operation. 

From these statistics it will be seen that the fatalities arising 
from aural diseases are chiefly those of purulent origin. An occa- 
sional fatality follows traumatism and hemorrhage. 

Partial deafness, whether catarrhal or the result of former 
purulent disease, does not materially vitiate the individual as a risk 
for life insurance. Profound deafness adds simply the moderate 
risk of death or injury arising from the individual's inability to 
give heed to those warnings which are symbolized by sound signals. 
Considering aural affections as a whole, it becomes obvious that 
the chief dangers to life resulting therefrom arise from the compli- 
cations of purulent invasion of the middle ear and especially the 
chronic type of this troublesome disease. 

The most dangerous complication of purulent otitis is osseous 
necrosis, whereby infection extends to the venous sinuses, the 
labyrinth, and the meninges. These complications are prone to 
occur at any time, but are more prevalent between the ages of 
sixteen and thirty years. Individuals who suffer from chronic 
purulent otitis are slightly more susceptible to other forms of 
chronic disease, notably tuberculosis. 

A careful study of the rules followed by a large number of life- 
insurance companies indicates that but little discrimination is 
exercised by their medical departments in classifying the different 
degrees of purulent aural disease., the tendency being to penalize all 
such applicants by insuring them as substandard risks or by adding 
materially to the premium rate. The majority of companies are 
inclined to overestimate the danger to life attendant upon middle- 
ear diseases. Furthermore, with a more careful discrimination as 
to the variety, character and extent of the disease, many prospect- 
ive insurers, now rejected or penalized, might safely be accepted 
at the usual premium rates. 

It is also important to record the relation which the radical 
mastoid operation performed for the cure of chronic purulent 
otitis media bears to life insurance. Thorough eradication of the 
entire area of necrosis, both of bony and soft tissues, with all 
surfaces finally healed and covered with healthy skin, practically 



400 DISEASES OF THE PERCEPTIVE APPARATUS. 

places the ear in a condition whereby it no longer becomes a menace 
to life. From a life-insurance standpoint, therefore, it would seem 
that this operation, when successfully performed upon a person 
otherwise insurable, should render him safely insurable without 
penalty or prolonged postponement. 

The following suggestions are ventured for guidance in classi- 
fying those with defective audition or disease of the auditory 
apparatus : — 

Simple catarrhal otitis, with or without deafness, aside from 
the possible danger of accidents, does not menace life. Chronic, 
non-purulent disease of the labyrinth, while more serious than 
catarrhal otitis media, does not materially tend to shorten life. 
Acute purulent otitis media, in an otherwise healthy individual, 
should not debar him as a safe risk beyond the time necessary for 
complete recovery, a period usually of from one to six weeks. 
Recurrent purulent middle-ear inflammation, especially in early 
life, usually results from some form of intranasal infection, and is 
commonly associated with adenoid growths in the vault of the 
pharynx or hypertrophied tonsils, and subsides promptly and 
permanently as soon as these have been removed, after which time 
such applicants should be considered safely insurable. A large 
proportion of the serious intracranial complications of middle-ear 
suppuration occurs in chronic purulent otitis media, and the statis- 
tics above mentioned clearly prove that such complications occur 
with sufficient frequency to render the victims of this type of ear 
disease less favorable as life-insurance risks. Chronic purulent 
otitis media attended with continuous discharge, with foul odor, 
especially when accompanied with excessive granulations, indicates 
necrosis, and therefore becomes the most serious type of ear disease. 
Such applicants should be considered bad risks under all circum- 
stances until a cure has been effected either by local treatment or 
radical operative interference. Large perforations and free drain- 
age, while militating in favor of the applicant, should not be con- 
sidered a positive guarantee against extension of the necrotic 
process to deeper structures. 

The radical operation successfully performed in an otherwise 
healthy individual should, after a reasonable time, render him 
safely insurable. 

Malignant neoplasms involving any portion of the auditory 
apparatus menace the individual's life to the same degree as when 
occurring in other portions of the body. Aural syphilis, tuber- 
culosis, lupus and cholesteatoma are likewise inimical to longevity. 
All pathological conditions, whether associated with purulency or 
not, need to be accorded full consideration. Non-malignant types 
of aural disease, which are classified as sebaceous cysts, hemato- 
mata, perichondritis, frostbite and eczema, do not exert any 
material effect upon longevity. 

In important cases, especially where large amounts are desired, 
the opinion of an expert otologist should be of value in deciding the 
degree of danger in the individual case. 



MISCELLANEOUS OTITIC CONDITIONS. 401 

AURAL SYMPTOMS OF NEURASTHENIA. 

Functional aural disturbances are occasionally observed in con- 
nection with the neurasthenic state. Inability of the patient to 
endure any form of prolonged nervous or mental strain, which is 
characteristic of neurasthenia, is sometimes evidenced by marked 
disturbance of the hearing function. 

Symptoms. — Tinnitus is the most frequent symptom of neuras- 
thenic aural disturbances. The character of the tinnitus is variable, 
the noises changing from time to time, and it is aggravated by 
fatigue, anger and emotions. Pain is another prominent symptom 
of neurasthenia, and it frequently occurs in association with the 
tinnitus. 

During the morning, after complete rest, all disturbing symp- 
toms are usually absent, only to return after even moderately pro- 
longed effort to carry on conversation or to concentrate the auditory 
function, with marked depression which often amounts to hypo- 
chondriasis, or even mild insanity. A roaring tinnitus is usually 
present, which is always aggravated by fatigue. There is a sense 
of fullness or irritation in the region of the Eustachian tube, and an 
apparent tendency to rapid fluctuations in the hearing power. 

Diagnosis. — The diagnosis is not usually difficult, especially 
when the general neurasthenic condition is marked. The drum 
membrane is usually normal in. appearance, and unless fatigued 
the hearing is good. Neurasthenics are prone to exaggerate all 
symptoms, and to give undue prominence to the slightest abnormal- 
ity. Hyperacusis is usually present. 

Prognosis. — When not accompanied by organic changes in the 
auditory apparatus the prognosis is good in those who finally 
recover from the underlying neurosis. 

Treatment. — From the nature of the affection it is obvious that 
the aural treatment is secondary to that of the general health. 
These patients should be given the most optimistic statements as 
to prognosis, and be encouraged to make every effort to cease from 
worry about their hearing. Internal medication in the form of 
strychnia and bromids may occasionally be of some service, but is 
not to be relied upon. A complete change of scene and mode of 
life, with rather strenuous, healthful exercise and plain diet, give 
the best results. 

MALINGERING (SIMULATED DEAFNESS). 

Among the neuroses there are various types of malingering 
which are difficult to differentiate from actual disease. The under- 
lying motives are either of a hysterical nature or are dishonest 
attempts to feign deafness for the purpose of avoiding service in 
various capacities, work in general, or blackmail to collect damages. 

Simulated deafness may be recognized by various methods. 
It is important that the otologist, who is often called upon to 
determine the true facts, be able by a series of tests to determine 
the true status of each individual case. A preliminary examination 

26 



402 DISEASES OF THE PERCEPTIVE APPARATUS. 

of the auricle, external meatus, drumhead and Eustachian tube 
should be made. If no lesion or pathological changes are discovered 
and no objective signs of ear disease are present the tests may- 
be continued. Many of these individuals have given considerable 
study to the subjective symptoms of middle-ear and labyrinthine 
deafness, and are peculiarly shrewd in carrying out their attempts 
to deceive. They usually simulate unilateral deafness. 

It is important to make all tests with the eyes of the patient 
bandaged, in order to prevent him from making use of his visual 
judgment of distances. After tightly plugging the normal ear, if 
he shows a tendency to vary the distance at which he hears the 
voice or acoumetre, it may be assumed that he is malingering. In 
this manner the Chimani-Moos test is carried out. 

A large-sized vibrating tuning fork, C 2 , is held alternately at 
an equal distance from each ear. In this manner it becomes self- 
evident that the tone is heard better in the ear which is claimed 
to be sound. The vibrating tuning fork is then placed on the 
median line of the vertex, or against the incisor teeth, and the 
patient asked to indicate in which ear the tone is better perceived. 
The patient with true aural disease affecting the sound-conducting 
apparatus will state without hesitation that he hears the tone much 
louder in the diseased ear, while the malingerer, after hesitating 
for a moment, inasmuch as he is really unable to distinguish any 
difference of perception in the two ears, thinks he is answering 
correctly by stating that he hears the tone in the normal ear. If, 
then, the external meatus of the normal ear is tightly closed and the 
vibrating fork is again placed upon the vertex or incisor teeth, the 
individual, if really deaf, will now say that he hears the tone better 
in the closed normal ear; or, he may no longer be able to distinguish 
on which side he perceives the tone. The malingerer, with the 
normal ear tightly closed, will state that he does not hear the 
tuning fork placed upon the vertex or incisor teeth at all. 

Erhard's Test. — If the external meatus of a normal ear is 
tightly packed it will still conduct the sound waves to a limited 
extent, a loud-ticking watch being heard at a distance of 2 or 3 m. 
Erhard places the malingerer in the middle of a large room, closes 
the ear which is said to be deaf, and then brings a loud-ticking 
watch gradually toward the normal ear and orders the patient to 
count the beats. The normal ear is then tightly closed and the 
supposed diseased ear examined. If the malingerer claims that he 
does not hear the watch-tick at a distance of 1 or 2 m. (the distance 
at which the tick should be heard in the closed normal ear), simula- 
tion should be suspected. 

It is sometimes possible to detect simulated unilateral deaf- 
ness by means of an ordinary stethoscope by plugging one of the 
tubes. Here the closed tube of the stethoscope should be placed in 
the normal ear and the open tube in the suspected ear. The patient 
should then be directed to repeat the words spoken by the examiner 
into the bell of the stethoscope. After removing the instrument 
the patient's normal ear should be tightly closed and the same 



MISCELLANEOUS OTITIC CONDITIONS. 403 

words repeated to him. If he now says he cannot hear the words 
which he has already repeated when the normal ear was tightly 
closed with the plugged earpiece of the stethoscope, he will have 
furnished sufficient evidence of malingering. The author's noise 
producer (Fig. 242) is also a valuable aid. 

To these tests must be added the importance of the experience 
and trained eye of the examiner, who will often be able to forge 
a chain of evidence from a succession of minor evidences of decep- 
tion, made up of contradictions recorded from repeated examina- 
tions, and overzealous statements as to the nature and cause of 
the affection. Chimani lays much stress upon the general appear- 
ance of. the individual, his temperament, peculiarities of facial 
expression and speech. 

The more extreme procedures, such as testing the hearing 
capacity of a person who has just awakened from sound sleep, or 
who has recovered from narcosis, are hardly necessary. Boisseau 
suggests, in bilateral deafness, the making of insulting remarks 
concerning the patient in his presence, during which a close obser- 
vation of his face will sometimes betray by flushing or changes of 
expression which indicate the existence of auditory perception. 

REQUIREMENTS OF THE UNITED STATES ARMY AND NAVY 

IN REGARD TO THE HEARING OF APPLICANTS 

FOR ENLISTMENT. 

The following rules are from the manual for examination of 
recruits : — 

1. For admission to the army. "Tumors or growths in the 
passage to the external ear may be at once discovered, and are 
causes for rejection." 

"The discharge of 'matter' from the ear is generally an evidence 
of diseased condition of the parts within, which is very likely to 
lead to permanent deafness, and is, therefore, a cause for rejection." 

"Deafness of either ear constitutes an absolute cause of rejec- 
tion." 

"As the distance at which the natural tone of voice may be 
heard in a closed room, when both ears are normal, is about 50 
feet, the distance at which the applicant is to stand from the 
examiner must be as great as the apartments will allow, not to 
exceed 50 feet." 

"The applicant will stand with his back to the examiner, who 
is to address him in a natural tone of voice. When the distance 
is less than 40 feet, it should be specified on the examination form, 
and the tone of voice will be lowered. Failure of the applicant to 
respond to the address of the examiner will demonstrate a defect." 

"The personal attention of the recruiting officer or sergeant 
must be given to closing the entrance to each ear separately, by 
pressing with the thumb the small lobe (tragus') situated in front 
of the opening to the inner ear." 

"Advantage should be taken of the absence of other sounds 



404 DISEASES OF THE PERCEPTIVE APPARATUS. 

to make the examination. Recruiting officers should remember 
that a man may be totally deaf in one ear, and yet may hear all 
ordinary conversation perfectly if the sound ear is not completely 
stopped. Deafness of one ear is a bar to enlistment, but in ordinary 
occupations it might not be observed." 

"Deafness may be caused by an accumulation of hardened 
wax; therefore an otherwise desirable recruit should have his ears 
well cleansed before final action is taken in his case." 

"All men enlisted for the artillery arm of the service at a 
military post or assigned to that arm from a depot shall, before 
such enlistment or assignment, besides undergoing the ordinary 
examination, be examined especially with a view to establishing 
the fact of the patency of the Eustachian tubes and the integrity of 
the tympanic membranes, in default of which the men are unfit 
for that arm." 

"In time of war deafness of one ear is not cause for rejection. 
It should be borne in mind that defects in hearing are easily 
feigned ; therefore, when they are alleged by conscripts, the 
examination should be made by a medical officer. Genuine deaf- 
ness cannot be concealed." 

2. For admission to the navy. "In the physical examina- 
tion of recruits for the naval service the ears are examined for 
polypi, otorrhea, perforation of the tympanic membranes, and 
dullness of hearing, and, should one or more of these conditions be 
found, the candidate is rejected. Polypi of the nose and chronic 
nasal catarrh are also causes for rejection. The hearing is tested 
by the voice, and, if necessary, by the ticking of the watch, as in 
all cases for admission to the Naval Academy, Annapolis, Md." 



HYSTERIA OF THE EAR. 

The otologist is occasionally consulted in relation to unusual 
aural manifestations which can only be accounted for as hysterical 
phenomena. Aural hysteria may occur in hysterical patients in 
whom there are no evidences of pathological changes in the auditory 
apparatus. In another class there are indications of pathological 
changes sufficient to produce tinnitus and loss of hearing, and in a 
third variety the patients have undergone operations upon the ear 
and are able to simulate the true symptoms of the disease. A 
fourth and unusual type of hysteria is found in patients who exhibit 
self-inflicted injuries in order to excite sympathy and secure gratui- 
ties. In all varieties it is evident that psychical influences no less 
than physical conditions are clearly in evidence. 

The most common variety is among patients in whom are 
found moderate pathological changes in the auditory apparatus, 
but which are still insufficient to evoke the symptoms complained 
of. All aural surgeons of large experience are repeatedly impor- 
tuned to perform mastoid operations upon those who feign 
mastoiditis. 

The diagnosis of aural hysteria is often attended with great 



MISCELLANEOUS OTITIC CONDITIONS. 405 

difficulty, and in many instances is accomplished only by process 
of elimination, hence it is incumbent upon the surgeon in the 
interests of humanity to avoid designating a real sufferer as a 
hysteric. 

Christian Holmes 8 has presented an exhaustive essay upon 
hysteria of the ear, wherein he advises that all cases of hysteria, 
whether in a normal or pathological ear, should receive treatment 
from a neurologist ; that no operation should be undertaken merely 
to satisfy their minds, and that every possible encouragement and 
psychical influence should be brought to bear upon the patient. 

Prognosis. — The prognosis, while not always positively good, 
is favorable, especially among patients who are tractable, and who 
are able, by a change in their mode of life, to derive the full benefits 
of travel, proper exercise and diet. 

Autosuggestion, if intelligently employed, is often of great 
benefit. 



8 Transactions of the American Laryngological, Rhinological and O to- 
logical Society, 1907, p. 107. 



PART II. 

The Influence of General Diseases upon 
the Ear, Nose and Throat. 



CHAPTER XXIX. 
INTRODUCTION. 

A comprehensive knowledge of the deleterious effects which 
general diseases and local organic affections may produce upon the 
ear, nose and throat is indispensable in determining the diagnosis, 
prognosis, and treatment of the local manifestations within these 
organs. It will thus be seen that when such etiological factors as 
are typified by scarlatina, tuberculosis and syphilis are productive 
of lesions in the ear, nose and throat, the prognosis must differ 
widely from that which obtains when the ear lesion is idiopathic. 

Local congestions and inflammations involving these organs 
are often only the effect of some general dyscrasia or pathological 
condition. Therefore, a just conception of any local abnormal 
condition in the ear, nose or throat, barring those of idiopathic 
origin, cannot be attained by merely considering these organs 
alone. 

General diseases are the causation of pathological changes in 
the ear, nose and throat in one or more of the following ways : — 

1. By lowering the general and local vitality of the tissues as 
a result of the introduction of poisons into the blood, thus increas- 
ing the vulnerability of the cells to the point where the ever-present 
bacteria can begin to thrive. 

2. By abnormal deposits (gouty, rheumatic). 

3. By venous stasis, which is brought about by cardiac failure 
of compensation, or some interference with the return circulation. 

4. By direct inoculation of pathogenic bacteria or protozoa. 

5. By infectious metastasis through the blood lymphatics. 

6. By local nerve paralysis, thereby causing interference with 
the normal physiology of the part. For example — paralysis of the 
soft palate prevents proper ventilation of the middle ear and thus 
tends to incite catarrhal otitis media ; paralysis of the recurrent 
laryngeal nerves interferes with phonation and respiration. Paraly- 
sis of the nerves of special sense causes loss of these functions. 

7. By excessive use and abuse of the organs ; pharyngitis 
resulting from emesis in cases of gastritis, or the excessive coughing 
of pertussis, etc. 

8. By hemorrhage from general diseases, examples of which 
are found in labyrinthine deafness of hemorrhagic origin, nasal 
hemorrhage from cirrhosis and purpura hemorrhagica. 

(406) 



TUBERCULOSIS AND LUPUS. 407 

9. By deformities from deep ulcerations. Those in the naso- 
pharynx sometimes interfere with nasal breathing or cause stricture 
of the Eustachian orifices, with the production of chronic catarrhal 
otitis media ; those in the larynx cause aphonia, dyspnea and 
dysphagia; those in the middle or internal ear cause tinnitus and 
deafness. 

10. By improper nourishment of the nerves of special sense. 

11. Cerebral, instances of which are deafness in uremia and 
paralysis in apoplexy. 

12. Inflammation (posterior poliomyelitis) of the cranial 
ganglia, said to produce herpetic attacks about the face and auricle. 

13. Reflex causes, uterine, puberty, etc. 

TUBERCULOSIS OF THE EAR, NOSE AND THROAT. 

General Remarks. — Tuberculosis of the ear, nose and throat 
occurs in two forms : the acute form, or that which complicates 
general tuberculosis, and the chronic form (lupus), which is a local 
lesion. Griinwald divides the lesions into the endogenous (the 
infection reaching the part through the lymph or blood-stream), 
and exogenous (which is purely local and due to direct inocula- 
tion). Lupus is tuberculosis produced by non- virulent, attenuated 
tubercle bacilli. It is probable that in a majority of cases of lupus 
the primary lesion is in the mucosa of the upper respiratory tract, 
notably that of the nasal septum, the lesions of the skin about the 
face being secondary. The initial lesion is a miliary tubercle 
modified by the virulence of the infection, the tissue resistance, the 
depth of the inoculation, and the character of the tissue wherein 
the process starts. The tubercle here, as elsewhere in the body, 
consists of clumps of epithelioid cells produced by proliferation of 
the endothelial and connective-tissue cells, with or without the 
production of giant cells, and it is usually distributed in the sub- 
epithelial region. 

The vast majority of tuberculous lesions in the ear, nose and 
throat, barring the local lesions induced by lupus, are secondary 
to pulmonary involvement. Notwithstanding the lack of physical 
signs of tuberculosis in the lungs in many cases, it is usually pos- 
sible to find the tubercle bacillus in the sputum, and to obtain 
subsequent confirmatory evidence of the disease. The paths of 
infection are either by direct inoculation through the bacillus-laden 
sputum, by means of the respired air, by the ingestion of infected 
food, by the fingers, by instrumentation, or by the blood or lymph 
streams. 

The tubercle bacillus (Fig. 266) gains access to the lymph 
spaces through the ducts of the glands or through abrasions. They 
are found in the lymphatic channels, and the changes commence- as 
cell proliferations around these vessels (Jobson Home). 

This explains the clinical fact that in the larynx the disease 
shows a predilection to attack the portions which are most abund- 
antly supplied with lymphatics — the arytenoids, the interarytenoid 



408 



IXFLUENXE OF GENERAL DISEASES. 



space and the epiglottis. The bovine type of tubercle bacillus is 
depicted in Fig. 267. 

The proportion of tubercle bacilli varies. When the disease is 
acute, they are, as a rule, numerous ; when chronic, few and difficult 
to find. The course of the tubercle tends to central caseation and 
necrosis, with exfoliation of the overlying mucosa as a result of 
thrombosis of its terminal blood-vessels. In rare instances the 
tubercle terminates in fibroid encapsulation. Tuberculous complica- 
tions of the upper respiratory tract are commoner in men than in 
women. They are more frequent during the decade from 20 to 30 
years. The severity of the primary pulmonary lesion has no 
apparent relation to the local complication. 

The prognosis as to life and ultimate health depends, as a rule, 
upon the condition of the lungs. When the process is advancing 




Fig. 266. — Tubercle bacillus. (Human type.) 



in the latter, the local lesion progresses whether situated in the ear, 
the nose or the throat ; on the other hand, when the condition is 
stationary in the lungs, the disease is quiescent elsewhere. There- 
fore, in all secondary cases the general treatment must aim chiefly 
to conserve the vital forces and increase nutrition. The essentials 
of treatment are proper diet, proper air, proper rest and proper 
environment. 

Much effort is put forth at present to determine the value of 
specific toxin tests in the diagnosis of tuberculosis. Hypodermic 
injections of various tuberculins, their instillation into the con- 
junctival sac (Calmette ophthalmic reaction), and the epidermal 
vaccination as advised by Pirquet are no longer in the experimental 
stage. The value of some of these toxins (tuberculins) and anti- 
toxins (Maragliano, Marmorek and others) is yet to be determined. 

Very little has been accomplished as yet with radium and 
X-ray therapy in the treatment of tuberculosis. In lupus the X-ray 
has produced more favorable results. 



TUBERCULOSIS AND LUPUS. 



409 



The determination of the opsonic indices (see Chapter VIII) 
also promises to be of value in the diagnosis, prognosis and treat- 
ment. The deleterious effects of pregnancy upon laryngeal tuber- 
culosis have been repeatedly demonstrated. 



TUBERCULOSIS OF THE EAR. 

Etiology. — Tuberculosis of the ear occurs in two forms, the 
acute and the chronic (or lupus). 

Primary acute tuberculosis of the ear is rare. It is generally 
.secondary to that of the lungs, and the most common pathway of 
infection is by the Eustachian tube, either extending by contiguity 
of the submucous tissues of the tube or, more often, through the 
lumen; rarely the path is through an existing perforation in the 




Fig. 267. — Tubercle bacillus. (Bovine type.) 

membrana tympani. . In miliary tuberculosis the advance is through 
the blood-vessels. 

A bilateral lesion occurs more frequently in tuberculosis than 
in all other forms of inflammatory conditions of the ear, 32.3 per 
cent, of bilateral inflammations of the middle ear being tuberculous, 
according to Bezold. 

A. Bordes estimates that 65 per cent, of all discharging ears 
in children are tuberculous in origin. Fowler subjected 50 patients 
suffering with purulent otitis media to the Calmette test, the diag- 
nostic value of which is open to considerable doubt. Of that 
number there were 29 chronic cases with 27 positive reactions. 
Fifteen were acute with 4 positive reactions and 6 had acute 
mastoiditis with 2 positive reactions. In children aural tuber- 
culosis may occur in what is apparently fair health and without 
evidences of tuberculosis elsewhere. In adults the disease usually 
is secondary. 

Symptoms. — The initial symptoms of tuberculous inflamma- 



410 INFLUENCE OF GENERAL DISEASES. 

tion of the middle ear differ from those of an ordinary acute puru- 
lent process. Often the first symptom noticed is a slight discharge 
without any pain preceding it. Blake and Buck contend that infil- 
tration and perforation of the posterosuperior quadrant of the 
drum membrane developing without pain is quite characteristic of 
middle-ear tuberculosis. Previous to the onset of symptoms the 
drum membrane appears hyperemic and dotted at one or two 
points with pearl-gray circumscribed spots. Multiple perforations 
(Fig. 175 ) and rapid' formation of granulations or the advent of 
facial paralysis point to a tuberculous origin. Ordinarily, the dis- 
charge is the first symptom noticed, and the accompanying per- 
forations enlarge rapidly. A similar rapid necrosis attacks the 
ossicles and neighboring bony structures. There seems to be 
almost no reaction of the tissues microscopically to the destroying 
influence, and tubercle bacilli are rarely found, even in serious cases. 

In no other form of otitis media purulenta chronica is complete 
deafness so liable to occur. In fatal cases among children tuber- 
culous meningitis is the usual cause of death. The discharge from 
the ear is usually thin and fetid. Bezold describes an exudate from 
the middle ear found about the promontory, with nearly total 
destruction of the membrana tympani, in which the tubercle bacilli 
are present in pure culture. 

Pathology. — The primary involvement of the membrana 
tympani and the soft tissues of the tympanum is followed by 
necrosis of the promontory, the ossicles, the annular ring, and the 
attic. The process may extend in all directions even to the mastoid 
process, facial and carotid canals, and the labyrinth, with destruc- 
tion of their contents. Intracranial complications are less frequent 
than in other acute infectious diseases ; the necrotic process may 
progress until the dura or sigmoid sinus is uncovered and thickened, 
with granulations, and yet gives no symptoms. Tuberculous granu- 
lations in the middle ear are pale and usually surrounded by fatty 
secretion. The perforations in the membrana tympani are large, 
owing to the tuberculous inflammation, and the mucous membrane 
of the tympanum is denuded in places, leaving bare exposed 
necrotic bone. The bony areas are necrotic to all degrees, with 
exfoliation in spots. Erosion of the internal carotid artery occa- 
sionally occurs in tuberculous individuals, and occasionally the 
entire petrous segment becomes necrosed, separates, and is removed 
en masse. 

Diagnosis. — A chronic purulent otitis media, when occurring 
in a tuberculous individual, is attended with rapid destruction of 
the membrana tympani, double or multiple perforations, and absence 
of pain as an initial symptom. Furthermore large exposed areas 
of denuded bone in the tympanic cavity are strongly suggestive of a 
tuberculous process. The finding of tubercle bacilli in the discharge, 
or their demonstration by inoculation of guinea-pigs, renders the 
diagnosis positive. 

Prognosis. — The disease is very rarely cured except in cases 



TUBERCULOSIS AND LUPUS. 



411 



where the general tuberculous process subsides. The fatal issue 
is usually the result of the disease in the lungs. 

Tuberculous meningitis, brain abscess, or sinus-thrombosis are 
rare but dangerous sequelae. The prognosis is especially bad in 
acute cases which rapidly invade the labyrinth and facial nerve, and 
also where the tubercle bacilli are abundant, except in those rare 
fibroid cases, mentioned by Bezold, in which, although tubercle 
bacilli are present in pure culture, the process seems to be very 




Fig. 268. — Extensive lupus vulgaris of the face, nose, mouth, ears 
and neck. (From collection of Dr. John A. Fordyce.) 



mild and amenable to treatment. The prognosis of tuberculous 
mastoiditis in infants is unfavorable. 

Local Treatment. — The external auditory canal and tympanic 
cavity should be kept clean by frequent douching, and all debris 
and discharge wiped away in order that good drainage may be 
maintained. 

The advent of severe pain with persistent profuse secretion, 
and the appearance of granulations in the meatus and large areas 
of denuded bone indicate with great certainty the presence of large 
sequestra, which should be removed regardless of how far the 
general disease has progressed. In advanced cases it may not be 



412 INFLUENCE OF GENERAL DISEASES. 

possible to remove all diseased tissue, but the curetment should 
be sufficient to relieve the pain and establish drainage. 

The radical mastoid operation provides the only means for 
eradicating the diseased bone when the aditus, mastoid antrum, and 
mastoid cells are involved. Whether or not it should be performed 
depends upon the general condition of the patient. If the disease 
in the lungs is quiescent and there is no wasting or hectic fever, the 
operation may be attempted with safety and with considerable 
hope of a successful outcome. In advanced tuberculosis it is 
dangerous and, therefore, contraindicated. In the primary form 
of tuberculous mastoiditis occurring in children the radical opera- 
tion is feasible and recovery is the rule. 

Lupus (Chronic Tuberculosis) of the Auricle. 

All forms of lupus vulgaris are found upon the auricle, and 
almost invariably the disease is associated with extensive lupus 
of the face (Fig. 268), from which it has extended to the ear. It 
develops in the form of lupus maculosus, exulcerans, hypertro- 
phicus, and papillaris. The disease here, as elsewhere, is prone to 
change from one form to another, commencing with small, brownish, 
scaly tubercles in groups, and gradually changing into those which 
involve the deep subcutaneous tissue. Ulceration sometimes follows 
or the tubercles may gradually shrink, and in process of involution 
they produce cicatrices, which have the appearance of keloid scars, and, 
while there is destruction of normal tissue, ajnass of cicatricial tissue 
of irregular size and shape is left behind. 

Lupus Exulcerans. 

The ulcerative form sometimes spreads from the cheek to the 
auricle, causing ulceration. The ulcers vary in size, are usually 
located upon the anterior portion of the auricle, and the ulcerating 
tubercles are covered with thick crusts, while their bases appear 
spongy and granular. In neglected cases there is more or less 
destruction of cartilage. The edges of the ulcers are often punched 
out, and, frequently, typical nodules are scattered in the cutis. 

Lupus Hypertrophicus. 

This is an obstinate and grave type which generally develops 
from a neglected ulcerative form. Papillary granulations spring 
from the bases of the ulcers, which are spongy, bleed easily, and 
continue to separate at different points, producing marked involve- 
ment and destruction of the cartilage, with deformity from the 
resultant necroses and contraction. 

Gradenigo has reported a case where the primary disease in 
the pharynx extended through the Eustachian tube into the middle 
and inner ear. 



TUBERCULOSIS AND LUPUS. 413 

Treatment. — Lupus, wherever located, is an intractable disease. 
Many dermatologists favor curetment of the skin lesions, combined 
with the Finsen phototherapy and the X-ray, the latter having 
many advocates. 

Deep-seated lupus of the auricle often necessitates excision of 
the entire diseased area. The actual cautery is effective in destroy- 
ing lupus ; but, unfortunately, produces an excessive amount of 
scar tissue. A paste of arsenious acid 20 per cent, in gum acacia is 
efficacious in some cases. Curetment is always indicated for the 
removal of ulcers and granulations. Radium is of questionable 
value, and injections with tuberculin preparations for tuberculosis 
of the skin have so far been disappointing. 

Lupus Erythematosus. 

This affection, which is a "chronic non-tuberculous disease of 
the skin, marked by disc-like patches with raised reddish edges and 
depressed centres, is covered with scales, which fall off, leaving dull, 
white cicatrices." 1 

The patches do not ulcerate, no deformity results, and the 
cicatrices tend to atrophy. It may appear upon the nose, face, ear, 
and mucous membranes. 

Trautman in analysis of 30 cases found involvement of the lips 
in 43 per cent., the mucous membrane of the cheeks in 40 per cent., 
the palate in 33 per cent., the tongue, tonsils, gums, the nasal, con- 
junctival, and laryngeal membranes in a small percentage of cases. 

Some authors claim a relationship of lupus erythematosus to 
lupus hypertrophicus. With this theory the author does not agree, 
inasmuch as the underlying pathological changes differ so widely. 

TUBERCULOSIS OF THE NOSE. 

Etiology and Pathology. — The nose is the least liable to acute 
tuberculous invasion of any portion of the respiratory tract, and its 
occurrence is seldom of primary origin. The chronic form — lupus 
— is more common. Tubercle bacilli gain lodgment in the nose in 
two ways: 1, through the air current, or by direct inoculation; 2, 
through the blood or lymphatics. The disease occurs in two forms, 
the acute miliary, which is secondary to pulmonary tuberculosis, 
and the chronic, which is usually designated as lupus. The acute 
miliary form is extremely rare and does not invade the bony struc- 
tures of the nose. The ulceration begins as small granules about 
the size of a millet seed, separated by areas of healthy mucous 
membrane, and is located upon the anterior part of the septum or 
floor of the nose. The ulcers are grayish in color, with edges of 
irregular outline. Millard and Hajek report having seen cases in 
this stage, but the ulceration is so rapid that the process is not. as a 
rule, discerned until the first stage is passed. Tubercle bacilli in 
large numbers are found in the discharge. The later manifesta- 

1 The American Illustrated Medical Dictionary. 



414 INFLUENCE OF GENERAL DISEASES. 

tions are deep ulceration and the edges of the ulcers are undermined 
and surrounded by an area of miliary tubercles. The disease 
rapidly spreads to the anterior nasal fossae, anterior part of the 
septum, and upper lip. 

There is a form of tuberculosis of the nose termed tuberculo- 
mata, which has the appearance of hyperplastic growths. They are 
reddish gray in color, vary in size from a bean to a hickory nut, 
and are usually located on the inferior turbinated bone. Escat and 
many others contend that all tuberculous affections of the nose are 
lupoid in character. 

Diagnosis. — The diagnosis is based upon the presence of 
advanced pulmonary or laryngeal tuberculosis, with all its train 
of severe constitutional symptoms, and the presence of the charac- 
teristic bacilli and ulcers within the nose. 

Ballenger 2 reports a case of primary tuberculosis of the nose of 
long standing, but its nodular appearance and cicatricial borders 
clearly indicate lupus vulgaris exedens. 

Prognosis. — The prognosis is unfavorable, and local treatment 
is palliative. 

Lupus of the Nose. 

All known forms of lupus vulgaris occur about the cutaneous 
and mucous surfaces of the nose, the nodular, hypertrophic, 
exedens, papillaris and maculosus (Fig. 268). The character and 
extent of the disease is dependent upon the form, stage, and severity 
which the lupus has assumed. 

The disease is described by Caboche under four headings : 
(a) nodular, (b) 7'cgctatiiig, (c) tumor, and (d) ulcerating. 

(a) Nodular. — This form is characterized by nodules which 
are two or three times the size of a pinhead. The surfaces are 
roughened and are pale rose-colored, and the individual nodules 
are separated by small, irregular grooves. Sometimes the latter 
become ulcerated, causing cicatricial, nipple-like lobules. 

The nodular type usually originates in the mucosa of the 
anterior part of the nasal fossae. 

(b) / 'cgctating. — In the vegetating variety, also called lupus 
hypertrophicus, there is extensive hyperplasia of a pale-rose or bluish- 
lilac color. There is usually a formation of crusts upon the vegeta- 
tions, which are separated by little grooves. The vegetations feel soft 
to a probe or curet. 

(c) Tumor. — The appearance of the nasal mucosa in the tumor 
variety is that of pedunculated or sessile tumors, which may fill the 
entire nasal cavity. These wart-like growths are pale bluish white 
with a red tinge. On superficial examination the gross appearance 
is smooth, but actually the surface is covered with- elevations about 
the size of a millet seed. The lupus tumor is elastic, bleeds little 
or not at all on probing, and usually is accompanied by some other 
manifestations of lupus. 



2 Diseases of the Nose, Throat and Ear. 



TUBERCULOSIS AND LUPUS. 415 

(d) Ulcerating. — Ulceration may occur in any type of the 
disease and at any stage of the process. The borders of the ulcera- 
tion are irregular and cicatrized areas are present in advanced 
cases. The base is granular, sometimes necrotic, and is surrounded 
by a zone of lupus nodules. 

Etiology of Lupus. — The disease is due to the invasions of the 
tubercle bacillus, but its slow development, tendency to heal, 
cicatrize and recur, and its purely local character serve to differ- 




Fig. 269. — Lupus vulgaris. The anterior portion of the septal cartilage 
and the alse nasi are partially destroyed. Absence of pigment is due in 
great measure to X-ray applications. (From collection of Dr. John A. 
Fordyce.) 

entiate it from virulent ulcerative tuberculosis. The disease is 
more common in females than in males (75 per cent., according to 
Caboche), and it occurs during middle life from about 20 to 50 
years. 

Pathology. — The mucous membrane over the septal cartilage, 
the floor of the nose and the anterior part of the inferior turbinal 
are most frequently involved. The cartilage itself becomes in- 
volved later, but the bone never. The septal cartilage is easily 
perforated if the lupus nodules occur on both sides. In 200 cases 
seen by Mygind perforation occurred in 29 per cent. The perfora- 



416 INFLUENCE OF GENERAL DISEASES. 

tion is rounded and regular and of varying size. The septal 
perforation alone rarely causes deformity of the nose. The anterior 
limit of the septal perforations is at the junction of the septal 
mucous membrane and the skin. The border of the perforation is 
commonl} fungoid and soft, bleeds easily and is considerably 
thickened. Pari i E the edge may be thin and healed, while the 
remainder is thickened and ulcerated. Stenotic deformities may 
follow in the healing. There may be various degrees of fibrous 
tissue formation, the process breaking down in one place and 
healing in another. This fibrosis may cause atrophy of the inferior 
turbinal. In severe and neglected cases the septal cartilage and 
alae nasi may be destroyed (Fig. 269), producing a terrible death's- 
head appearance. The accompanying lymphangitis gives a red and 
swollen aspect to the end of the nose. 

The disease tend'- to extend outward upon the cutaneous sur- 
faces, where it pursues a slow and insidious course and with typical 
symptoms i Figs. 269 and 284 I. 

Symptoms. — In lupus there may be no symptoms for years, 
perhaps some lachrymation or a rebellious dermatitis of the vesti- 
bule, "i" a torpid and recurring lymphangitis of the alae and tip of 
the nose may be all that is noticed. As the disease progresses 
obstructive symptoms supervene, with mucopurulent discharge. 
The ulcerative stage is characterized by a thicker purulent secretion 
with an occasional admixture of blood. Occasionally the spreading 
of the process to the pharynx or larynx will produce symptoms 
which result in an examination of the nose and the discovery of the 
initial process there. 

The cutaneous symptoms are lymphangitis and the appearance 
■ if -roups of nodules, which may coalesce or ulcerate with resultant 
cicatrices. There are periods of active progress of the disease which 
are followed by healing with keloid-appearing scars. Recurrences 
are the rule and always with some extension into new tissue. 
Deformity is marked whenever the alae have been partially or 
wholly destroyed. 

Diagnosis. — Recurring lobular lymphangitis, persistent uni- 
lateral dermatitis about the vestibule, and epiphora should direct 
attention to the parts of election for lupus in the nasal mucosa. 
Chronic rhinitis sometimes gives a mammillated appearance to the 
nasal mucosa, but the surfaces are smooth, bluish and without ulcera- 
tions. An advanced syphiloma should not be mistaken for lupus. 
Its rapid progress, smooth appearance, early breaking down into 
one or two ulcers and its involvement of bone are all quite the 
opposite of lupus. In recent syphilitic perforations of the septum 
denuded bone can nearly always be detected with the probe; in 
lupus never, except when bone has been exposed by cauterizing 
agents. In lupus the lesion never exists without similar lesions in 
the neighboring mucosa. 

Finally, in doubt fid cases resort may be had to the Wasser- 
iiKiiin test, antisyphilitic medication, microscopic examination or 
to inoculation in order to ascertain the nature of the suspected 
lesion. 



TUBERCULOSIS AND LUPUS. 417 

Prognosis. — Lupus is amenable to treatment, and while recur- 
rence is probable the treatment materially retards its progress. 
Spontaneous recovery is possible. Sometimes lupus extends to the 
larynx and lungs and causes death from pulmonary tuberculosis. 
The slowness of the process allows hope of eradication, but com- 
plications may set in even in the apparently cured cases, with rapid 
ending. The disease tends to extend in all directions, involving at 
times the skin, frequently the lachrymal duct, either as a simple 
or specific inflammation. It seldom involves the nasal sinuses. 

Treatment. — No form of treatment will cure all cases and 
recurrences are common. In a communication from John A. 
Fordyce he states : "The chief advance in our treatment of tuber- 
culosis (lupus) in recent years is the Finsen and Roentgen-ray 
treatment. -Lupus of the anterior nares, in a large percentage of 
cases, involves the mucous membrane and is influenced in a degree 
by X-rays applied within the nostril. Lately I have had a modifica- 
tion of the Cornell tube made which enables me to apply the rays 
for some distance inside the nostrils. This can be done with greater 
ease where there has been destruction of the alse. Where the lesion 
is beyond the influence of X-rays we have nothing better than 
destruction of the tissue with the galvanic cautery, the dental burr 
of Fox, the curet or the usual chemical caustics." 

After removal by surgical methods the surfaces may be treated 
locally by applications of the following formula : — 

R; Iodin 1 part. 

Potassium iodid 2 parts. 

Distilled water 2 parts. 

The X-ray yields brilliant results in some cases and fails utterly 
in others. 

Hollander advises the employment of nascent iodid of mercury 
as follows : — 

Fifteen minutes before treatment two drams of a 5 per cent, 
potassium iodid solution is taken. Then an application of powdered 
calomel is made to the lesion. The iodin eliminated from the 
mucosa combines with the calomel and gives rise to nascent iodid 
of mercury, which has a most energetic action. 

In the vegetating form Caboche advises the application of 
tampons containing 80 per cent, lactic acid for twenty-five to thirty 
minutes. In the still more extensive and vegetating forms he 
curets, under chloroform anesthesia, and then applies 75 per cent, 
lactic acid tamponings three times a week. He claims that the 
mammillated infiltration disappears rapidly, leaving a regular 
mucosa, smooth and normal. 

TUBERCULOSIS OF THE ACCESSORY SINUSES. 

In postmortems on tuberculous patients the sinuses have been 
found involved in from 20 to 50 per cent, of cases. Tn the living, 
however, positive symptoms of tuberculous sinus disease are rarely 
found. Primary tuberculosis of the antrum of Highmore has been 

27 



418 INFLUENCE OF GENERAL DISEASES. 

reported in only a few instances, but the process is generally sec- 
ondary and in rare instances it may begin in the bone instead of the 
mucous membrane. 

The treatment is the same as in the chronic suppurative cases, 
but must be more radical, and the results are less favorable. 

TUBERCULOSIS OF THE MOUTH AND PHARYNX. 

Tuberculosis of the mouth and pharynx is a rare affection, but 
during recent years there has been a tendency to carefully differen- 
tiate the lesions of these organs and the microscope has been a 
valuable aid. 

The result has shown a vast increase in the reports of cases 
and is suggestive that the affection is more common than had 
previously been supposed. 

In the mouth tuberculosis attacks the lips, cheeks, gums (Fig. 
270), hard palate, soft palate (Fig. 271), tongue (Fig. 272), teeth 
and alveolar process. In the pharynx the disease attacks the tonsils 
(Fig. 273), soft palate, faucial pillars and posterior pharyngeal wall 
(Fig. 271). The lesions rarely occur singly and are probably 
secondary to that of the larynx and lungs in the majority of cases, 
primary development being rare. 

According to Levy, the classifications are two in number, the 
benign and malignant, or, according to Griinwald, the endogenous 
and the exogenous. Levy contends that "the exogenous or ascend- 
ing form, that which may be designated as the inoculation variety 
or purely local, represents the less active, sluggish or benign 
type, while the endogenous or descending variety, that which rep- 
resents infection through blood and lymph streams, through miliary 
deposits or infection from within, corresponds to the more active, 
virulent, malignant type." 

Etiology. — The disease is more common in males, and in 
rare cases the only demonstrable lesion is in the mouth or pharynx, 
thus furnishing some tangible evidence that local irritation and 
membranous abrasions are causative factors. But Angay's 3 con- 
tention that the most frequent mode of infection is through the 
blood-current, while probably borne out by clinical experience, the 
lymph-current furnishes almost or quite as convenient a pathway 
for the transmission of infection. On the lips it occurs in the form 
of ulcer. On the tongue it starts as a small granule upon the 
dorsum or at the border. This in turn ulcerates and the resultant 
ulcers are surrounded by irregular edges and covered by caseous 
spots. The cervical glands near the angle of the jaw are seldom 
affected and the salivary glands are almost immune from tuber- 
culosis, only a few cases having been reported. 

The disease is characterized by miliary tubercles and is asso- 
ciated with the miliary form of tuberculosis of the lungs. The 
affection is more common in the tonsils than in other areas of the 



3 International Centralblatt fiir Laryngologie, 1896, p. 212. 







Fig. 27U— Tul 



-Tuberculous ulceration of the gums. (F« 



f the Mouth." h 



obert Lwji, with permissioi 







/ 



^ 



^>y 



Fig 271— Tuberculous ulceration of the hard palate, soft palate, 
uvula and posterior wall of the pharynx. (From "Tuberculosis of the 
Mouth." Robert Levy, with permission.) 




Fig. 272. — Tuberculous ulceration of the tongue. (From a patient 
of Dr. J. C. Sharp, with permission.) 



■A 



'£ 



/ 



J s 



■p 






Fig. 273. — Tuberculous ulceration of the tonsils. (From "Tuberculosis 
of the Mouth." Robert Levy, with permission.) 



TUBERCULOSIS AND LUPUS. 419 

mouth and pharynx. Wood (1904) contends that "the tonsillar 
tissue of the throat, because of its peculiar anatomical construction 
and its topographic relations, is more liable to become infected by- 
tuberculosis than any other part of the upper respiratory tract." 
A. Latham found by inoculation that 7 out of 45 consecutive 
cases of hypertrophy of the tonsils in children, ages ranging from 
three months to fifteen years, were tuberculous. Ordinary enlarged 
tonsils and adenoids rarely contain tuberculous nodules (Bezold). 
The tonsils are affected in nearly all cases of advanced pulmonary 
tuberculosis, and 5 per cent, of all cases of hypertrophy of the 
pharyngeal tonsil are tuberculous (G. B. Wood). Others have 
from time to time reported undoubted cases of primary tuberculosis 
of the tonsils. Secondary tuberculosis of the tonsils generally 
assumes the form of ulceration. With chronic cervical adenitis, if 
tuberculosis is suspected, attention should be directed to the lym- 
phoid ring. 

Infiltration of the faucial tonsil with miliary tubercles cannot 
be positively determined except by the microscope or by inocu- 
lation. 

Pathology. — The miliary tubercles develop in the submucous 
tissue. The margins of the ulcerations are irregular and at first 
small and discrete, separated by infiltrated tissues. These break 
down and produce a mouse-nibbled appearance. There is no sur- 
rounding zone of congestion and inflammation as seen in other 
ulcers. The surrounding mucosa is. pale and anemic. The ulcers 
are not so punched out as in syphilis, and are bathed in a small 
amount of mucopus. Cervical adenitis is generally present. The 
ulcers tend to spread laterally and not deeply. The base of the 
ulcers is covered with a dirty-white secretion, and on cleansing are 
more or less nodular. Scattered over the ulcerated surface and on 
its margins may be found small, red granulations, interspersed with 
yellow or grayish pinhead spots (Trelot). 

Jonathan Wright has divided the tuberculous lesions of the 
tonsils into three forms: 1. Irregular, shallow erosions of the epi- 
thelium of the crypts, with no previous formation of tubercles, no 
caseous metamorphosis, no giant cells. The floor of the ulcer is 
formed by infiltrated lymphoid tissue. Tubercle bacilli in great 
numbers are also found in the contents of the crypts, which are 
yellowish white and contain thick matter with no odor. Cervical 
adenitis is a late symptom. 

2. Typical tubercles, with giant cells and caseous degenera- 
tion. The ulcers are deeper than in the first variety. 

3. Diffuse tuberculous infiltration where the tonsil loses most of 
its normal tissue and is surrounded by a fibrous capsule covered 
with mucosa. 

Tn tuberculosis of the pharyngeal tonsil tubercle bacilli are few 
and giant cells common. The lingual tonsil is occasionally affected. 

Symptoms. — Tuberculosis of the mouth and fauces ma_v exist 
for months without producing troublesome symptoms. . In the 
miliary form the general symptoms usually overshadow those in 



420 INFLUENCE OF GENERAL DISEASES. 

the pharynx. Discrete ulcers may occur in severe types when 
accompanied by general infection. Pain is never marked during 
the early stages and its advent is in the form of burning sensations 
during deglutition. During the later stages pain becomes severe. 
When the ulcers are on the posterior pharyngeal wall or in the 
tonsils (Figs. 271 and 273) the pain radiates to the ears. There is 
considerable localized infiltration about the ulcers and considerable 
secretion of grayish, viscid mucus. The advent of tissue necrosis 
is marked by odor. Emaciation develops rapidly on account of 
insufficient nourishment and the ravages of the disease. There is 
reflex cough, hectic temperature, and when the soft palate is 
involved liquids pass into the nose and nasopharynx. The muco- 
pus is allowed to accumulate on account of the pain, and efforts to 
clear the throat are accompanied by a gurgling, rattling sound, 
which is also heard during respiration. 

Upon examination in the acute miliary form there is at first 
a studding with grayish, translucent spots, varying in size from 
a small pinhead to a millet seed. These project above the mucous 
membrane, which is very anemic. There is generally considerable 
edema of the soft palate and uvula, sometimes occurring in small 
defined areas scattered uniformly, which in appearance are not 
unlike sudamina on the skin. In a few days they ulcerate and 
gradually coalesce. Thick, tenacious mucopus exudes from the 
ulcers. Tubercle bacilli are very few, and are more often found in 
the marginal scrapings. Sometimes, in indolent cases, excessive 
granulation tissue forms, hiding the ulcer. In this form marked 
enlargement of the cervical lymph glands occurs. 

Diagnosis. — Tuberculous ulcerations are of superficial, pale, 
worm-eaten aspect, with yellowish spots and minute elevations 
scattered over the surface, and without inflammatory borders, and 
the diagnosis is confirmed by detection of the tubercle bacillus 
under the microscope, by outlining the typical tubercle structures 
in stained secretions, and by inoculation of guinea-pigs. General 
tuberculosis is usually present. 

Differential Diagnosis. — The disease should be differentiated 
from syphilis, diphtheria and lupus. The tuberculous ulcer is seldom 
primary and is more painful than the syphilitic. The outlines are 
more irregular, the margins less elevated and congested, and there 
is less excavation. It does not respond to specific treatment. 
Mixed cases are said to occur. When in doubt a microscopic 
examination of a section or inoculation is indicated. 

In diphtheria there is a pinkish membrane, which is removed 
with difficulty, leaving a bleeding surface. There is no membrane 
formation in tuberculosis, and the secretion is readily sponged off. 
The margins of a diphtheritic ulcer are deeply inflamed, while the 
margins are pale in tuberculosis. The Klebs-Loeffler bacillus 
instead of the tubercle bacillus is found in diphtheria. Diphtheritic 
ulcer disappears in a few days ; tuberculous ulcer gradually extends. 

In lupus the development is slow, while in acute tuberculosis 
there is a more rapid ulcerative process. There is no temperature 



TUBERCULOSIS AND LUPUS. 421 

in lupus, and no pain. There are nodular deposits near the ulcerated 
areas in lupus; none in acute tuberculosis. Cicatrices over healed 
areas are found in lupus; rarely in tuberculosis. 

Prognosis. — A very few cases of acute tuberculosis of the 
mouth and pharynx have been reported healed. The great majority 
succumb in from a few days to a few weeks. 

Treatment. — The treatment is mainly palliative, although cura- 
tive measures, both local and general, are indicated. Palliative 
measures are chiefly efficacious for the relief of pain. The ulcers 
should be kept clean by alkaline sprays and various dusting powders 
applied. These tend to retard the activity of the disease and allay 
the pain. Powdered orthoform is valuable for the relief of pain. 
Mild astringents, such as sprays of sulphate or chlorid of zinc, 
4 grains to the ounce, may be employed. Sprays of menthol, 3 per 
cent., cocaine, 5 per cent., are helpful measures for the relief of pain. 
Morphine powder, gr. %, in starch, gr. iij, may be dusted over the 
surface of the ulcers. If the condition warrants, discrete ulcers 
may be curetted with a sharp curet and the base touched with 
lactic acid, repeating the latter applications every four days. Mean- 
while the ulcers should be cleansed several times a day with 
alkaline washes. Occasionally a cure of the ulcer is thus effected, 
but the patient generally succumbs to the process in the lungs. 

On the principle that much of the pain is due to the develop- 
ment of neuromata on the exposed nerve filaments it is often justifi- 
able to use the above-named surgical measures even in hopeless 
cases. To relieve the pain during deglutition it is recommended 
that a spray of cocaine, 2 per cent., or a small ^4 grain pellet of 
cocaine be dissolved in the mouth a half hour before meals. Semi- 
solids are advised for diet since they are better tolerated. 

Lupus of the Mouth and Pharynx. 

Lupus of the mouth and pharynx is nearly always secondary 
to lupus of the nose or skin and manifests the same tendency to 
ulcerate, heal, cicatrize and recur. The tubercles coalesce or bunch 
together into nodules and ulcerate mildly and slowly without much 
secretion. Nodules occur in various stages, some healed, some 
ulcerating, some not broken down. Tubercle bacilli are very 
sparsely found in the nodules. 

Symptoms. — Stiffness of the part involved, which interferes 
with its function, is a prominent symptom. Deglutition is some- 
what impaired and there is a tendency for liquid food to regurgitate 
through the nose, and for the voice to acquire a nasal twang. The 
parts are more apt to be anesthetic than hyperesthetic. Complicat- 
ing cervical adenitis is common. 

Diagnosis. — The diagnosis is based upon the slow development, 
nodular formation, cicatricial borders, slight ulcerations, and slight 
discharge. The disease is painless, does not respond to iodids, and 
is readily differentiated from acute tuberculosis and malignant 
disease by the characteristic general and local symptoms and gross 
appearance. 



422 INFLUENCE OF GENERAL DISEASES. 

Treatment. — The treatment in the main is the same as that of 
lupus of the nasal mucosa. Mild cases of lupus of the palate are 
henefited by applications of equal parts of resorcin, balsam of Peru 
and mucilage. Fordyce injected tuberculin (B. E.) from Kooo °f a 
milligram to 1 milligram, after a modification of Wright's method, 
with marked improvement, but the improvement was not permanent 
and recurrence took place. 

TUBERCULOSIS OF THE LARYNX. 

This affection is variously described as consumption of the 
throat, laryngeal phthisis, and tuberculosis of the larynx. It is 
characterized by glandular and connective-tissue infiltration and 
ulceration. 

Etiology and Pathology. — Among laryngologists the belief is 
general that laryngeal tuberculosis is almost invariably a secondary 
affection, and this view is strongly supported by postmortem 
findings. Three cases of primary tuberculosis of the larynx have 
been authenticated by autopsy, thus showing the rare exceptions 
to the rule. 

It occurs at all ages, but most frequently between twenty and 
thirty. It is very rare in children. In fatal cases of pulmonary 
tuberculosis the larynx is involved in about one quarter of all cases'. 
Schroetter, of Vienna, found the larynx involved in only 6 per 
cent. ; Ileinze, of Leipzig, in 5 per cent, and Osier in 18 to 30 per 
cent. Parker states that 80 per cent, of larynxes are abnormal in 
phthisis, 50 per cent, being non-tuberculous lesions due to irritation 
of the cough and sputum, and 30 per cent, to true tubercle involve- 
ment. Kidd states that in 50 per cent, of the fatal phthisis cases 
there is some tuberculous lesion in the larynx, and clinically he 
observed it in 20 to 25 per cent, of cases. Laryngeal tuberculosis 
is more common in men than in women, about 2 l /i to 1, and it is 
very rare under ten years of age. Lake reports two cases of laryn- 
geal infection from tuberculosis of the ear. 

The laryngeal invasion may occur very early in the history of 
lung involvement, and be unilateral or bilateral. The point of 
entrance is said to be through the gland ducts in the ventricles 
(Wood), but the path of infection may be by direct inoculation, 
and also through the blood-stream. Simple lesions of the larynx 
are extremely common in phthisis due to coughing, which produces 
congestion. These abnormalities consist in anemic areas, chronic 
laryngitis, and abrasions, and they are due to irritation of the 
sputum or to the strain of coughing. Congested vessels are often 
seen coursing over anemic areas in the epiglottis, ventricular bands, 
and arytenoids, the rest of the mucous membrane being normal. 
Hyperemia of the vocal cords is common, even though the surround- 
ing mucosa is anemic. The disease appears to start in the lym- 
phatics within the larynx. The arytenoid and interarytenoid spaces 
are generously supplied with lymphatics, and hence are most fre- 
quently involved. Ulceration occurs early where the parts are sub- 



TUBERCULOSIS AND LUPUS. 423 

ject to attrition, such as the cords or vocal process, not so on the 
arytenoids or aryepiglottic folds. On the other hand, Osier contends 
that in laryngeal tuberculosis the primary lesion is in the neighbor- 
hood of the blood-vessels. The tuberculous deposits may be 
uniformly distributed over a considerable area and be massed into 
tumor formations. The ulcerations are usually superficial and 
irregular in outline, the margins are neither elevated nor surrounded 
by a zone of hyperemia, and tissue necrosis is rapid. Edema of the 
aryepiglottic folds is frequently observed. Ulceration of the epi- 
glottic folds, the epiglottis, vocal cords, posterior laryngeal wall, 
the interarytenoid region, and the ventricular bands marks the 
progress of the disease. Necrosis of the cartilages of the larynx 
is common. Dumond reports a case of acute cricoarytenoid arthri- 
tis in a case of tuberculous laryngitis, which caused a fixation of the 
cords in the median line, with much dyspnea. 

In miliary tuberculosis of the larynx the mucosa becomes dotted 
with small, roundish, yellow, millet-seed nodules, scattered or in 




Fig. 274. — Tuberculous infiltration of the epiglottis. 

groups, accompanied by general edema. There is a tendency for 
them to rapidly coalesce, soften and ulcerate. 

Subglottic edema is a serious, but rare complication. Limited 
infiltration, with or without superficial ulceration, and generally 
unilateral, occurs on the cords or ventricular bands. Infiltration 
about the arytenoids, aryepiglottic folds, or the epiglottis is prone 
to occur and the epiglottis may become so swollen as to be turban- 
shaped (Fig. 274). There is but little lymphatic gland involvement 
so long as the disease remains intrinsic. 

In the arytenoid region perineuritis of the recurrent nerves 
may occur. 

Symptoms. — In cases which have advanced to the ulcerative 
stage the symptoms are characteristic and the diagnosis is not 
difficult. By this time the general infection has produced emacia- 
tion, dyspnea, and pallor. The following are among the prominent 
symptoms of tuberculous laryngitis : — 

Changes in the Voice. — The initial symptoms of laryngeal infec- 
tion are hoarseness and changeable voice and a prickling sensation 
which induces cough during phonation. As the disease progresses 
the voice becomes more hoarse and changeable, being one day clear 
and the next hoarse. Extensive infiltration and ulceration cause 
complete aphonia. 

Dyspnea. — There is seldom laryngeal dyspnea unless the tume- 



424 



INFLUENCE OF GENERAL DISEASES. 



faction is very extensive. The cough is more often due to iung 
involvement than to laryngeal lesion, except when extensive ulcera- 
tion is present. 

Dysphagia. — Whenever the epiglottis or the aryepiglottic folds 
are ulcerated, dysphagia becomes a distressing symptom. Dys- 
phagia is evoked either by the contact of food passing over the 
ulcerated surfaces or by the movement of the larynx while coughing 
or speaking. Patients often refuse food for long periods on account of 
the dread of pain during deglutition. Deglutition is not painful so 
long as the ulceration is entirely intrinsic. 

Cough and Expectoration. — During the ulcerative stage of tuber- 
culous laryngitis there is increased mucopurulent secretion which 
may be streaked with blood. Cough is constant and painful. When 
the lungs are extensively diseased there is free expectoration. 




Fig. 275. — Tuberculous ulceration of the vocal cords. 

The Clinical Picture. — Upon examination of the larynx the 
mucous membrane appears pale, with small areas of congestion. 
During the early stage there is but little secretion, but when ulcera- 
tions are present they are constantly bathed in mucopurulent 
secretion. Pale, pear-shaped swellings in the neighborhood of the 
aryepiglottic folds, which obliterate the outlines of the cartilage of 
Wrisburg, are characteristic of the early stage of tuberculosis of the 
larynx. 

Small tubercles underneath the mucous membrane appear as 
small, grayish elevations the size of a pinhead. They are frequently 
seen on the epiglottis, aryepiglottic folds and ventricular bands. 
Tumor formations are common in the interarytenoid space and 
present a sessile, pedunculated or wart-like appearance. Any 
degree of arytenoid thickening, when complicating pulmonary tuber- 
culosis, is pathognomonic of laryngeal tuberculosis. 

Tuberculous ulceration of the larynx is usually accompanied by 
edema of the arvepiglottic folds. In epiglottic involvement the 
accompanying edema causes it to be thickened, swollen, pale and 
turban-shaped, so that it obstructs the view of the interior of the 
larynx (Fig. 274). Ulcers on the ventricular bands are irregular in 



TUBERCULOSIS AND LUPUS. 425 

outline, covered with a thin, gray or yellowish exudate, and the 
edema of the aryepiglottic fold is, as a rule, more marked on the side 
of the ulcer. Ulcers on the vocal cords (Fig. 275) are irregular- and 
often serrated in appearance. On phonation it is frequently seen 
that the cords do not approximate and that quite a space intervenes. 
There may be irregular action of the cords, with impaired mobility. 

Diagnosis. — The diagnosis is not difficult except during the 
early stage in patients with incipient or central pulmonary lesions. 
The positive diagnostic symptoms are: 1, history of tuberculosis; 
2, the presence of tubercle bacilli in the secretion; 3, the characteris- 
tic appearance of the larynx. The disease must be differentiated 
from syphilis, chronic laryngeal pachydermia, lupus, papillomata, 
and malignant growths. 

In chronic laryngitis and pachydermia laryngis (Chapter XLIX) 
there is no ulceration and both progress slowly, while tuberculous 
laryngitis is characterized by pallor of the mucosa and ulceration, 
and edema and loss of voice are common. 

In syphilis the process is usually more rapid, the ulcerations 
excavate deeper, the margins are more elevated and inflamed, and 
there is a greater amount of local secretion. When the tuberculous 
infiltration simulates syphilis the diagnosis may only be arrived at 
after medication with iodid of potassium. 

In lupus the nodule formation and slight superficial ulceration 
and cicatrization occurring in different parts of the larynx differ- 
entiate it from tuberculous ulceration, in which cicatrization is un- 
common. The nose, pharynx, mouth, and face are also invariably 
involved in lupus. 

Papillomata are localized warty or cauliflower-like tumors, and 
are never accompanied by the peculiar pear-shaped swellings of the 
arytenoids or the ulceration, which are characteristic of tuberculous 
laryngitis. But in tuberculous subjects the majority of the growths 
occurring in the larynx are tuberculous. 

Malignant growths have a distinct tumor-like dark-red appear- 
ance and the mucous membrane in the non-involved portion is 
always congested. Malignancy rarely occurs before the forty-fifth 
year, the pain is severe even before ulceration, and frequently 
radiates to the ears. There is early involvement of the laryngeal 
nerves and vessels, causing interference with the movements of the 
cords, and stenosis is common. An excised portion, examined 
microscopically, should clear the diagnosis. 

Cases of mixed infection occurring with a history of syphilis 
are sometimes extremely difficult to differentiate. These occur as 
hyperplastic growths, originating near the arytenoids or from the 
ventricle of Morgagni. They are pedunculated or sessile. Many 
times they do not seem to respond to antisyphilitic treatment and 
run a rapid course. 

Prognosis. — Acute pulmonary tuberculosis with laryngeal 
ulceration is a grave disease and nearly always fatal. Such patients 
seldom live more than a few weeks. Where the primary lesion is 
slow and confined to the apices, and the connective-tissue formation 



426 INFLUENCE OF GENERAL DISEASES. 

is more rapid than the cell proliferation, the disease may be arrested 
and occasionally cured. In rare cases where the laryngeal tissue is 
deeply congested and miliary tubercles are scattered through this 
area, ulceration rapidly ensues and the patient succumbs in a few 
weeks. In the tuberculous tumor cases the tendency to ulceration 
may be so slight that if the lungs improve there may be no ulcera- 
tion for years, and under favorable general and local treatment 
recovery may ensue. Should the tumor ulcerate, active surgical 
intervention may induce healing, providing the general health 
permits. Extensive ulceration of the larynx presages a rapidly 
fatal issue and operative interference is both useless and harmful. 
Tuberculous lesions of the larynx are usually in the same stage as 
those in the lungs with a like prognosis. 

Treatment. — A warm, equable, not too dry climate is favored 
for patients suffering from tuberculous laryngitis. The colder 
climates of the Adirondacks or of Colorado are not so good in 
winter. In southern California there are a few places, such as the 
Ojai Valley and Pasadena, that are ideal for this condition. The 
Riviera, Egypt and the Pine Belt of South Carolina are less 
healthful. 

The contraindications to removal to a different climate are 
rapid loss of flesh, diarrhea, dysphagia, persistent hemoptysis and 
dyspnea. 

Expert local treatment is invariably required ; it, therefore, 
becomes imperative for the patient to sojourn where this can be 
secured. 

Prophylaxis. — The larynx in all cases of phthisis should be 
closely watched. If local areas of anemia or hyperemia become 
apparent, steam inhalations, nebulization, sprays or intralaryngeal 
injections are advantageous, employing such medicaments as 
creosote, oleum pinus sylvestris, compound tincture of benzoin, 
menthol and oleum eucalypti. 

Chronic laryngitis and other non-tuberculous lesions of the 
larynx when complicating pulmonary tuberculosis should be treated 
according to the principles outlined in Chapter XLIX, inasmuch as 
they furnish a ripe field for infection by the sputum. If slight abra- 
sions or superficial ulcers accompany tuberculous laryngitis, they 
may be treated by applying a 50 per cent, solution of lactic acid 
every three or four days and by soothing, emollient sprays or vapors 
several times daily. 

Opinions differ widely upon the question of intralaryngeal 
surgery for the relief of tuberculosis of the larynx. Krause and 
Herzog, who were the pioneers in this field of surgery, claimed 
many cures (1886) from curetment and applications of lactic acid. 

Their views have received indorsement from many observers 
who have employed their methods with apparent prolongation of 
life and occasional cures. 

Opposed to the curetment method are Schrotter, Stoerck and 
others, who contend that the wound which is made by curetment 
of the laryngeal ulcers is extremely liable to reinfection from the 



TUBERCULOSIS AND LUPUS. 



427 



secretions; that the improvement is only temporary; that dysphagia 
is increased, and that the pulmonary disease and general wasting 
are thereby increased. 

Favorable cases for operation are those of localized infiltra- 
tion with slight ulcerations in individuals who are comparatively 




Fig. 276. — Krause-Heryng laryngeal 
cutting forceps. 



strong and in whom none of the ravages of the general disease are 
apparent. 

Moderate tuberculous infiltrations of slow growth do best when 
let alone, trusting to climatic and general measures for cure. In 
incipient cases, in favorable climates, under the watchful care of 
competent laryngologists, the tumors may gradually disappear or 



428 INFLUENCE OF GENERAL DISEASES. 

remain stationary for years. Local applications are indicated as 
soon as there is any evidence of ulceration and necrosis. If dyspnea 
is caused by the growth surgical procedure should not be long- 
delayed. Gallagher, Levy, Lockard, Johnson and others claim 
curative results from formaldehyd applied locally. Gallagher has 
especially emphasized the technique of its administration as fol- 
lows : — 

Procedure: — 

1. Slight cocaine anesthesia. 

2. Cleanse, and spray with 1 to 3 per cent, formaldehyd solution. 

3. Local applications of 5 to 10 per cent, formaldehyd solution. 

4. R Orthoform, 7 parts ) • ,, ffl „ + - „ 

Aristol, 1 part } insufflation. 

5. Deep intratracheal injection of: — 

R Menthol gr. x. 

01. eucalypti f3j. 

01. cinnamomi n\ j. 

Glycerol q. s. ad fsj. 




Fig. 277. — Killian laryngeal cutting forceps 



Surgical treatment is contraindicated whenever it is impossible 
to remove the diseased parts, in actively progressing or extensive 
disease in the lungs with rapid wasting, when hemoptysis is fre- 
quent and in cases of nervous instability, feebleness and old age. 

In the acute miliary form the treatment should be palliative 
only, as the disease is rapidly fatal. Extensive cutting operations 
require profound cocaine anesthesia. A 20 per cent, solution of 
cocaine applied locally to the tissues, at intervals of five minutes, for 
a period of thirty minutes, usually is sufficient. Growths and 
necrotic areas may then be removed with cutting forceps. For this 
purpose the Krause-Heryng (Fig. 276) or Killian (Fig. 277) cut- 
ting forceps is employed. 

It is important to limit curettage to the necrosed and ulcerated 
areas. After removal of the growth the denuded area is dried and 
then touched with lactic acid solution, 10 to 50 per cent., or pure 
nitric acid. Rapid healing must be promoted or reinfection will 
occur. For some days subsequent to operation the patient should 
avoid speaking, and coughing should be controlled by the adminis- 



TUBERCULOSIS AND LUPUS. 



429 



tration of codeine, heroin, etc. Laryngeal hemorrhage may be con- 
trolled by adrenalin sprays or applications of equal parts of lactic 
acid and liquor ferri chloridi (Heymann). 

Lake uses a combination of lactic acid, 50 per cent. ; formalin, 
7 per cent.; carbolic acid, 10 per cent., for applying to ulcerations 
in the larynx. He advises daily applications of the above, the 
carbolic acid acting as a local anesthetic and relieving some of the 
after-smarting. 

Dry inhalations from a mask placed over the nose and mouth 
and worn for thirty minutes, as often as needed, are useful as 
palliative measures. Parker suggests the following: Creosote, 




Fig. 278. — Yankauer laryngeal medicine dropper. 

80 minims to the ounce of alcohol ; oleum pini sylvestris, 40 minims 
to the ounce of alcohol ; oleum eucalypti, 80 minims to the ounce ; 
menthol, 80 minims to the ounce. A half dram to be poured on the 
mask. 

Dysphagia. — If eating semisolids causes pain and violent cough 
they may be sucked through a glass tube with the head hanging 
over the edge of the bed, thus preventing the food from entering 
the larynx (Wolfenden), and rectal alimentation may become neces- 
sary as a last resort. 

Spraying the larynx with a solution of cocaine 2 per cent, ten 
minutes before eating, or applying the same with cotton carrier 
offers relief. Insufflations of powdered orthoform are also effective 
in controlling pain. 

Amputation of the epiglottis is sometimes successful in easing 
the dysphagia when the ulceration involves the epiglottis. 

Yankauer has devised a long medicine dropper for dropping 
oily medications into the larynx (Fig. 278). The bent tip is adjusted 
to reach just beyond the uvula. 



430 



INFLUENCE OF GENERAL DISEASES. 



Leduc used an autoinsufflator (Fig. 279) which can be employed 
by the patient providing the physician cannot be seen daily. The 
short end is introduced nearly to the posterior wall of the pharynx, 
the lips are closed, and the powder inspired through two or three 
short breaths. By placing a rubber band just anterior to the teeth, 
after being properly adjusted, the correct distance of introduction 
will be known for the subsequent introductions. 

Radiotherapy. — The Finsen light, the Copper-Hewitt light, the 
Roentgen ray and radium have formed the medium of innumerable 
experiments for the relief of pain and the cure of laryngeal tuber- 
culosis, but so far have proved of no avail except for the relief of 
pain. 

Finally, if a cure for laryngeal tuberculosis is to be obtained, 
it will be secured only by the employment of all known means of 




Fig. 279.— Leduc's autoinsufflator 



treatment of both general tuberculosis and its complications; hence, 
but little may be expected from local medication or surgery of the 
larynx except when combined with all the more modern methods of 
management and treatment. 



Lupus of the Larynx. 

Etiology. — Primary lupus of the larynx is exceedingly rare. It 
is usually secondary to that in the pharynx, nose or face. 

Pathology. — The pathology is the same as that of lupus in the 
pharynx, heretofore described. 

Symptoms. — The voice becomes hoarse during the early stages, 
to be followed by complete aphonia when the true and false cords 
become involved. Dyspnea is very severe whenever the larynx 
becomes stenosed. There is an irritating cou^h with but slight 
secretion and no pain. Tubercle bacilli are seldom found. 

Examination. — As elsewhere, lupus in the larynx is observed 
in all stages, from the nodule to that of ulceration and cicatrization. 
It has the same general appearance here as described in the pharynx 



TUBERCULOSIS AND LUPUS. 431 

and nose. During the progress of cicatrization puckered white scars 
are produced, often causing great deformities. The disease usually 
commences in the epiglottis, thence extending to the aryepiglottic folds 
and ventricular bands. 

Prognosis. — Laryngeal lupus is practically never cured. It 
may be arrested for a time, but it will finally reappear and cause a 
fatal termination. 

Treatment. — Constitutional treatment is the same as for lupus 
in the pharynx. The nodules should be removed under cocaine and 
the bases painted with lactic acid in 10 to 50 per cent, solution the 
same as in other tuberculous lesions. The lactic acid applications 
should be repeated every three days until the ulcers have disap- 
peared. Tracheotomy may be required when dyspnea becomes 
urgent. 



CHAPTER XXX. 

THE IXFLUEXCE OF GEXERAL DISEASES UPOX THE 

EAR, XOSE AXD THROAT. 

(Continued.) 



SYPHILIS OF THE EAR, NOSE AND THROAT. 

General Remarks. — It is now quite generally conceded that 
the spirocheta pallida is the causal agent of syphilis. The initial 
lesion consists of diffuse infiltration of round cells in the papillae and 
mucosa, larger epithelioid cells, and giant cells. Conjointly a thick- 
ening of the intima of the small blood-vessels and changes in the 
nerve fibres of the part also take place (Berkley). In the second- 
ary lesion there is infiltration of the endothelial and plasma cells, 
interspersed between the loosened epithelial cells, many of the 
latter exhibiting nuclear fragmentation (J. Wright). The tertiary 
lesion is supposed to arise from secondary exudates left behind, 
consisting of proliferating endothelial and connective-tissue cells, 
epithelioid cells, and giant cells. Retrograde metamorphosis comes 
about by caseation or absorption beginning at the giant and 
epithelioid cells. 

The general specific treatment is more important than the 
local, which consists mostly in cleansing the affected parts. Treat- 
ment should be begun as soon as the diagnosis is certain, and 
should be as vigorous as the condition of the patient will permit. 

To embark upon the sea of specific medication is beyond the 
province of this book. Suffice it to say that the disease is amenable 
to medication, and it is of the utmost importance to curtail its 
ravages in order to avoid the disastrous deformities and trouble- 
some sequelae which sometimes obtain in the ear, nose, and throat. 
Few diseases respond so readily to definite specific treatment as 
does syphilis to mercury and iodin, and the reader is referred to 
appropriate text-books,and monographs for detailed information in 
regard to the employment of these remedies. 

The experiments of Ehrlich which have resulted in the dis- 
covery of a preparation which bore the name and also the number 
606, though now called salvarsan, mark a distinct advance in the treat- 
ment of syphilis, providing subsequent tests succeed in verifying the 
preliminary experiments. 

It is an arsenical preparation with the formula CioH^oOoXoAso 
and is administered hypodermically. The average dose is 0.5 and 
one dose is supposed to exterminate the spirocheta. It has been 
necessary to repeat the injection in a few instances. After injec- 
tion, the patient is obliged to remain in bed for two or three days 
and to refrain from his duties for about ten days. 
(432) 



SYPHILIS. 433 

A recent article by Fordyce 1 contains a report of his experi- 
ence in the use of this drug and an abstract of his conclusions is 
appended : — 

"This report is not intended to be conclusive, for in order to 
determine the value of any therapeutic agent observation of cases 
should extend over a long period of time; however, from an attitude 
of conservatism in the beginning of the treatment I am becoming 
impressed with the remarkable action of the drug, especially in the 
early period of the disease. One cannot fail to be convinced of the 
remarkable theraputic action of a drug capable of producing such 
decided improvement as occurred in the case of luetic endarteritis 
of the base, and in cases of obstinate gummatous ulceration which 
for years had been treated with mercury and potassium iodid with 
little or no result. The case of multiple initial lesions of the lip 
with secondaries, in which the Wassermann reaction has remained 
negative after a period of five months, would strongly support 
Professor Ehrlich's contention that it is possible with one dose, 
though that be a normal one, to completely eradicate the cause of 
the disease. 

"The drug exercises a remarkable influence over bodily nutri- 
tion, as evidenced by two cases which impressed me deeply. One 
of these, a medical man, had lost in weight and strength and was 
practically incapacitated for work. Two weeks after the injection 
his lesions were healed, his appetite was good, he gained in weight, 
and the nephritis which developed during the secondary stage of 
the disease had disappeared. 

"Owing to a wider use of the drug and the difficulties in pre- 
paring it, it will not be at all surprising if the results reported are 
lacking in uniformity or direct criticism against the drug when the 
error really lies in the manner of its preparation and the selection of 
suitable cases. Nor is it at all improbable that it will be given in 
many cases non-syphilitic under the mistaken diagnosis of syphilis, 
and condemned for that reason. Under such circumstances it is 
impossible from a review of the literature to be dogmatic regarding 
its use, and one must be guided rather by theoretical considerations 
and personal experience in the employment of the remedy. During 
the experimental stage there will probably be many adverse criti- 
cisms should relapse occur or one or two doses fail to relieve the 
active manifestations of the disease, but too much weight should 
jiot be given them, as they do not invalidate the underlying prin- 
ciples. In conclusion, I wish to emphasize that in 606 we possess a 
remedy which is parasitotropic for protozoan spirilla and is not 
indicated in other forms of infection. It acts specifically for lues 
with a rapidity and intensity superior to mercury and potassium 
iodid not only on the cause, but on the pathological products of the 
disease, accomplishing with one injection what the other remedies 
fail to do or for which they require much longer time to produce 
the same effect. Time can only answer the question as to the per- 



1 New York Medical Journal, November, 1910. 



434 INFLUENCE OF GENERAL DISEASES. 

manency of it's curative action or whether the combinatory method 
with mercury and potassium iodid should be employed." 

SYPHILIS OF THE EXTERNAL EAR. 

Primary syphilis of the external ear is a rare affection. Politzer 
reports three cases. Secondary manifestations are more common 
and generally occur in conjunction with similar eruptions (macular, 
papular, and pustular) on the forehead and scalp. Gummata are 
seldom observed in the external ear. In the external meatus, 
condylomata and ulcers are the most common forms of syphilis. 
The former occur as grayish-red, warty efflorescences which 
gradually increase in size and cause swelling and secretion from 
the external auditory canal. 

Symptoms. — At first there are no symptoms, but the advent of 
ulceration marks the commencement of pain of a lancinating charac- 
ter which is aggravated by movements of the jaw. At the same 
time subjective noises and deafness appear. Ulcers generally form 
on the posterior and inferior wall, are attended with profuse fetid 
discharge and a cure requires from a few weeks to several months 
of active local and general treatment. Papular infiltration has 
been observed on the membrana tympani. Gummata of the 
external ear are usually associated with syphilis of the tympanum. 
They may occur in the auricle, external auditory canal or mem- 
brana tympani. Exostoses of the canal sometimes result from 
syphilis. 

Treatment. — Locally the ulcerations and granulations should 
be cauterized with silver nitrate or chromic acid and the parts kept 
clean until healing is complete. When the growths are smaller 
tincture of iodin may be employed, or they may be dusted with 
calomel. 

SYPHILIS OF THE MIDDLE EAR. 

Etiology and Symptomatology. — Primary syphilis of the middle 
ear is possible only by extension per tubcm of a chancre of the 
pharynx, and its appearance in the tympanum is a rare occurrence. 
Ulcers and condylomata may cause strictures or atresia of the 
Eustachian tube. In the middle ear the process may set up a 
mucous or purulent inflammation. Women with hereditary syphilis, 
according to Gradenigo, are prone to develop otosclerosis between 
the ages of twenty and thirty years. 

When due to secondary or tertiary ulceration or hyperplasia, 
the hearing is markedly affected, especially when caries or necrosis 
is present. Facial paralysis, brain abscess and sinus-thrombosis 
are among the serious complications. Chronic suppurative otitis 
media is frequently associated with syphilis, and it probably results 
by contiguity from syphilis of the nasopharynx. Erosion of the 
internal carotid occurred in a case of secondary syphilis of the 
middle ear (Pilz). 

Diagnosis. — Diagnosis is often difficult and only possible (with- 



SYPHILIS. 435 

out a history of the disease elsewhere) when there is rapid destruc- 
tion of the tissues in non-tuberculous patients. Additional data of 
diagnostic value is obtained by using the Wassermann and Noguchi 
tests. Only positive findings with the Wassermann reaction are to 
be considered of value. Negative findings mean nothing. The test 
should be repeated a few times before a negative report is considered 
final. 

Prognosis. — The prognosis is favorable in the primary and 
secondary stages when properly treated. Ordinary cases in the 
tertiary stage recover under treatment, but the ultimate results 
upon the hearing in old cachectic individuals, or when the affection 
is complicated with granulomata, polypi, caries, and total deafness 
is very unfavorable. 

Treatment. — Early general treatment must be relied upon for 
cure. Local treatment is employed only for cleansing, drainage, 
and the removal of necrosed bone (Chapters VIII and XIX). 

SYPHILIS OF THE INTERNAL EAR. 

Syphilis of the internal ear occurs more often in the late second- 
ary or beginning tertiary stage, rarely before the skin eruption. 
Labyrinthine involvement may occur alone or in conjunction with 
inflammatory conditions of the middle ear. The labyrinth is said 
to be involved in from 7 to 48 per cent, of all internal-ear cases 
(Schwabach, Krelschmann, Wiese). 

Pathology. — The periosteal thickenings and infiltrations be- 
come more or less organized into connective tissue and the foot- 
plate of the stapes may become immobilized in some cases. Bone 
absorption sometimes occurs and is replaced with connective tissue. 
Hemorrhagic and other exudates may become densely organized, 
and infiltration may occur in the acoustic nerve. Politzer reports a 
case of infiltration in the ganglion cells in Rosenthal's canal. The 
internal-ear involvement may be a part of a purulent panotitis. 
Ecchymosis of the acoustic nerve has been demonstrated. 

Symptoms. — Symptomatologically the onset of the disease is 
sudden and its appearance is characterized by marked deafness, 
tinnitus, vertigo, and disturbance of equilibrium. Deafness is less 
liable to be progressive than in otosclerosis (Politzer). Intense 
tinnitus continues even after deafness becomes complete, but the 
vertigo may disappear in a few months. Diplacusis has been 
reported by Roosa, and Moos and Steinbrugge report cases of 
otalgia due to periosteal infiltrate in the labyrinth. There is noth- 
ing pathognomonic about the findings in the middle ear or Eusta- 
chian tube unless mucous patches or gummata are found therein. 
The mastoid lymph-glands may be much enlarged. Deafness is 
marked in most cases, generally both ears being affected to different 
degrees. The course is often very rapid; sometimes complete deaf- 
ness occurring within a few days. Improvement, when it occurs, 
comes about very slowly. 

Diagnosis. — Diagnosis mainly depends upon evidence of the 



436 INFLUENCE OF GENERAL DISEASES. 

disease in other parts of the body. Rapid development of deafness, 
without other middle-ear symptoms, in young individuals is very 
suspicious of tertiary syphilis. In a case of chronic non-purulent 
otitis media with rapid development of internal-ear deafness 
syphilis may be suspected. The diagnosis in cases which develop 
gradually is very difhcult. In childhood the rapid onset of deafness 
without demonstrable cause is nearly always due to congenital 
syphilis. According to Hutchinson and Jackson, 10 per cent, of all 
non-purulent deafness occurring in children is of syphilitic origin. 
Baratoux found it to occur in 33y s per cent. 

Prognosis. — The prognosis is very unfavorable in cases of long 
standing, less so in recent cases. It is unfavorable in old age, 
anemia, marasmus, and malignant syphilis. The congenital form is 
extremely obstinate. Relapses may also occur. 

Treatment. — The treatment is that of the general disease. 
Pilocarpine in a 2 per cent, solution subcutaneously administered, 
gradually increasing the dose from 4 to 12 drops daily, is recom- 
mended by Politzer and Bacon. This method in the author's 
experience has been of doubtful benefit, and his' chief reliance is 
placed upon the so-called "mixed treatment." 



SYPHILIS OF THE NOSE, MOUTH, PHARYNX, 
AND LARYNX. 

A. Primary (chancre). 

B. Secondary (erythema, mucous patch). 

C. Tertiary (gummata). 

D. Congenital. 

E. Syphilis of the accessory sinuses. 

A. PRIMARY SYPHILIS. 
Syphilis of the Nose. 

Etiology. — The nose is rarely' the seat of chancre. There are 
a few cases in literature in which it developed on the septum at the 
mucocutaneous juncture from picking the nose with an infected 
finger. It is usually located upon the alse at the junction of the 
mucous membrane (Fig. 280). 

Bulkley reports 95 primary lesions in the nose out of 9058 
cases of syphilis. Basserau, Clerq, le Forte. Fournier and Ricord 
found two primary lesions of the nose out of 2244 cases of syphilis. 

Syphilis of the Mouth and Pharynx. 

In the mouth and pharynx the disease is more common, 
chancres being found on the lips, tongue, palate, faucial pillars, 
tonsils, and, more rarely, on the posterior pharyngeal wall. 

The infection enters through broken or diseased mucous mem- 
brane as a result of kissing, perverted sexuality, or by contact with 



SYPHILIS. 437 

infected fingers, knives, forks, or the infected instruments of physi- 
cians and dentists. 

Texier reports a case of multiple chancre of the mouth and 
pharynx, one on each tonsil, and one on the lip. 

Syphilis of the Larynx. 

In the larynx primary chancre is very rare. Moure has reported 
a case wherein it occurred on the edge of the epiglottis, and Poyst 
one on the left ventricular band. 




-Primary chancre of the nose. (From collection of 
Dr. John A. Fordyce, with permission.) 

Symptoms. — The disease is characterized by a hard, indurated 
mass which appears upon the surface of the membrane, sometimes 
with slight ulceration, but with little discharge. There is little or 
no pain when it occurs upon the ala? or in the vestibule, but the 
swelling may interfere somewhat with nasal respiration. Epistaxis 
intervenes when ulceration is present. 

In the mouth and throat the chancre causes slight pain, which 
is usually mure marked during deglutition. The swelling is in- 
durated, and a grayish ulceration covered with thick mucus may 
occupy its centre. The cervical glands, especially those under the 
jaw of the affected side, become enlarged and extremely hard. 

Diagnosis. — The disease develops more rapidly than lupus or 
malignant neoplasms, and less rapidly than furuncle. Early enlarge- 
ment of the cervical glands is characteristic of syphilis. It may 



438 INFLUENCE OF GENERAL DISEASES. 

become necessary to wait for the appearance of secondary symp- 
toms, which appear in about six weeks, in order to establish the 
diagnosis. Ulceration in malignant diseases invariably progresses. 
That of syphilis is of small area and remains stationary. 

Prognosis. — The chancre disappears in a few weeks, leaving 
little or no scar. 

Treatment. — Beyond ordinary cleansing measures, no treat- 
ment should be employed until the diagnosis is positive, after 
which vigorous internal medication with mercury, according to 
approved methods, is imperative. 

B. SECONDARY SYPHILIS (ERYTHEMA, MUCOUS PATCH). 

Secondary syphilis occurs in the form of erythema, mucous 
patches, and superficial ulceration. In the nose this consists of a 
characteristic erythematous area or mucous patch located upon the 
mucous membrane. This mucous patch is unusual in the nose, 
and more common in the mouth and pharynx, where the secondary 
lesion appears in about six weeks subsequent to the initial chancre. 
Mucous patches, while not true ulcers, have the appearance of 
superficial ulcerated areas. They are the result of necrosis of the 
superficial epithelia, whereby these cells appear grayish white. 
They are perceptibly elevated above the mucous membrane, and 
surrounded by a zone of active hyperemia. 

In the pharynx they attack chiefly the soft palate and tonsils, 
but the sharply defined patches may spread over the anterior pillars 
and uvula. The patches are round or ovoid, ranging in size from 
a split pea to a bean. Mucous patches are persistent and tend to 
recur even in the tertiary stage. The larynx is less frequently the 
seat of mucous patches, but erythema is commonly seen in the 
early secondary stage of syphilis. Mucous patches occurring in the 
region of the larynx usually attack the epiglottis, vocal cords or 
arytenoids. Upon the cords they produce a red and white mottled 
appearance which is quite suggestive. 

Symptoms. — In the nose the symptoms are similar to those 
of acute rhinitis, although more lasting and persistent. There is 
a burning sensation within the nasal cavity, and sneezing is 
common. Nocturnal headaches are occasionally complained of. 
There is usually an accompanying sore throat, for the treatment 
of which the patient primarily applies. 

The mucous patches in the mouth and pharynx produce con- 
siderable pain, which is aggravated by muscular movements. The 
skin lesion precedes the mucous patch and becomes a valuable 
symptom for purposes of diagnosis. Headache is common, and 
the hair, eyebrows and beard may fall out in patches. 

In the larynx the symptoms are those of a mild chronic laryn- 
gitis. There is hoarseness and a slight secretion, which gives rise 
to a cough and clearing of the throat. Dysphagia occurs only 
when the epiglottis or aryepiglottic folds become involved. 

Diagnosis. — The typical mucous patches are quite characteris- 







Fig. 281. — Gumma of the tongue healing. Male aged 30. Resulting 
from syphilis three years ago. (From collection of Dr. John A. Fordyce, 
with permission.) 




Fig. 282. — Interstitial glossitis. Syphilis 6 years old. Patient 
chews tobacco and drinks. Mouth sore for 5 years; the same con- 
dition, he says, as now exists. Tongue is thickened, fissured and seat 
of leucokeratosis. The same condition of leucokeratosis extends back 
along line of teeth from angles of the mouth. (From collection of Dr. 
John A. Fordyce, with permission.) 



SYPHILIS. 439 

tic in appearance and are accompanied by enlargement of the sub- 
occipital, cervical, femoral and inguinal glands. These symptoms, ' 
in conjunction with the various syphilides of the skin and occa- 
sional warty excrescences, combine to render an early diagnosis 
comparatively easy. 

Prognosis. — Under appropriate treatment the mucous patches 
disappear in from two to six weeks, leaving no trace. Reappear- 
ance is common up to two years, when the treatment is neglected. 

When appearing upon the vocal cords there is usually a slight 
impairment of voice subsequent to their disappearance. 

Treatment. — The chief reliance must be placed upon appro- 
priate internal medication (see text-books on general medicine). 
Some benefit arises from applications of fused nitrate of silver 
upon the surface of the patches every three days, and all secretions 
should be frequently washed away by means of alkaline sprays. 
On account of the extreme contagiousness of secondary syphilis 
of the mouth and pharynx, special knives, forks, cups, glasses, etc., 
should be employed, and these should be washed separately. 
Kissing and other forms of contact should be forbidden. Warty 
excrescences when present may- be destro3^ed by fused chromic 
acid or nitrate of silver, and the mouth frequently cleansed with a 
solution of potassium chlorid, 12 grs. to the ounce, and chlorid of 
zinc, 10 grs. to the ounce. 

C. TERTIARY SYPHILIS (GUMMA). 

The characteristic lesions of tertiary syphilis rarely appear 
under two years from the date of the primary lesion ; more often 
fully five years elapse, and gummata may appear even after fifteen 
or twenty years. The pathological appearances are those of the 
gumma, the ulcerated or broken-down gumma, necrosis of carti- 
lage, and bone, and, finally, resultant deformities, scars and adhe- 
sions. All stages of gummata are found in the nose, appearing in 
the tissues of the septum, the bony framework or the alse. They 
usually break down rapidly, but may remain stationary for some 
time. In this location they are circumscribed, nodular or diffuse, 
the latter form being more common. Upon breaking down they 
result in deep ulcers and necrosis of cartilage and bone. 

In the mouth and pharynx the gummata appear upon the 
posterior pharyngeal wall, hard palate, faucial pillars, tongue (Fig. 
281) or tonsils. They are indurated swellings, which are either 
circumscribed or diffuse. They are round or oval, ranging in size 
from a small pea to a hickory nut. They are found on the 
epiglottis, aryepiglottic folds, ventricular bands and walls of the 
larynx. When multiple they produce a lobulated appearance (Fig. 
282 ). The growth is rapid and necrosis occurs early. 

The pathological changes in the ulcerative stage depend upon 
the situation and depth of the involvement. In the epiglottis there 
may be partial or total destruction of the cartilage, and the ulcera- 
tion mav extend into the base of the tongue. Ulceration of the 



440 



IXFLUEN'CE OF GENERAL DISEASES. 



aryepiglottic folds often causes twisting of the epiglottis, due to the 
contracting cicatrix, with narrowing of the introitus of the larynx. 

In other cases the arytenoids become necrosed, resulting in 
deformity, and ankylosis of the cricoarytenoid articulations. When- 
ever the ventricular bands become ulcerated there is much loss of 
tissue, which may extend to the true cords. After healing a variety 
of deformities and adhesions forms, some of which are prone to 
cause atresia of the larynx. 

Symptoms. — The appearance of gummata within the nose is 
usually characterized by the manifold symptoms of nasal obstruc- 
tion. Pain soon appears, is worse at night, and becomes intensified 
as necrosis develops. 




Fig. 283. — Nasal deformity (saddle-back) resulting from syphilitic 
necrosis of the nasal and turbinate bones. 



Necrosis and ulceration are accompanied by a discharge of 
foul mucopus, and the formation of masses of thick scabs, which are 
blown from the nose. Particles of necrosed bone may also be 
blown or otherwise removed from the nasal cavities. Bare and 
loose bones are easily detected with the probe, the vomer being 
most frequently involved. The masses of retained necrosed bone 
emit a foul stench. Opinions vary as to whether atrophic rhinitis 
with ozena may sometimes be of syphilitic origin. 

The nasal and turbinal bones often become necrosed and 
separate from their attachments, resulting in external saddle-back 
and other deformities (Fig. 283). Adhesions, nasal stenosis, polypi, 
and a variety of internal deformities result from the ravages of 
tertiary nasal syphilis. The most serious of these deformities 
are: — 

1. Collapse of the entire anterior third of the nose (Fig. 284). 



SYPHILIS 



441 



2. Sinking in of the entire nostril so that only the slits of the 
nostril project. 

3. Destruction of the ake and complete nasal stenosis. 

In the Pharynx. — Syphilitic gummata when occurring in the 
nasopharynx are usually found upon the posterior wall in the form 
of swellings, which may vary in size. They give rise to pain, altered 
voice and sometimes difficulty in deglutition; nasal respiration is 
interfered with, and regurgitation of liquids into the nasopharynx 
and out through the nasal passages is common. Upon breaking- 
down the surface becomes ulcerated, with a mucopurulent dis- 
charge into the oropharynx. Large ulcers are liable to develop 
upon the upper wall of the soft palate, the granulations from which 




Fig. 284. — Collapse of anterior portion of nose. The subject of this 
particular photograph is a victim of lupus and not of syphilis. 

are prone to result in adhesions of the soft palate to the posterior 
wall, a very distressing sequela of this disease. Syphilitic perfora- 
tions of the soft palate produce voice sounds similar to those of 
cleft palate, and liquids and food pass through the perforations 
into the nose. 

Nodular gummata generally appear on the soft palate and 
resemble lupus, the surface appearing rough and thickened. Both 
superficial and deep ulcers accompany the tertiary lesion, the 
former in the early tertiary, and the latter during the later stages. 
Gummatous ulcers present a round, punched-out appearance, with 
irregular margins and excavated centres, which are covered with 
sloughing tissue and foul secretion. 

A variety of deformities results from the destruction of tissue 
and from the contracting cicatrices. Adhesion of the posterior 
pillars to the posterior pharyngeal wall produces atresia. Adhesion 



442 



INFLUENCE OF GENERAL DISEASES. 



of the soft palate to the posterior pharyngeal wall is the commonest 
form (Fig. 285) and the results are disastrous to nasal breathing 
•and the proper ventilation of the middle ear. Constriction of the 
pharyngeal ostium and the Eustachian tube may result. 

Of the Larynx. — The tertiary manifestations of syphilis in the 
larynx are in the order of their occurrence : — 

1. Gummata; 2, ulcerations; 3, perichondritis and necrosis of 
tissue; 4, the resultant scars, deformities, and adhesions. 




Fig. 285.— Cicatricial adhesion of the soft palate to the posterior 
pharyngeal wall. 

Gummata may appear in any portion of the larynx and are 
either diffuse or circumscribed. They are found upon the epiglot- 
tis, arytenoids, vocal cords, and the ventricles. They are deep-red, 
oval-appearing swellings, surrounded by inflammatory areas. 
They tend to break down rapidly and ulcerate. 

The first manifestation of ulceration is the appearance of a 
small, yellowish central area. Syphilitic ulcerations of the^ larynx 
are usually deep and extensive, with the appearance of being 
punched out. The edges are sharp and well defined, and sur- 
rounded with a red and edematous areola. They invariably occur 
as sequelae of gummata. The ulcerated surfaces are covered with 
portions of necrosed tissue, which are bathed in pus. 



SYPHILIS. 



443 



As the ulcerative process extends, the perichondrium and the 
laryngeal cartilages become the seat of a gummatous infiltra- 
tion. This stage is characterized by marked swelling of the soft 
tissues, abscess formations and necrosis of the cartilages. Necrosis 
of the cartilages is attended with extensive destruction of the 
laryngeal tissues. Whenever the epiglottis is the seat of a gumma 
there is a sensation as of a lump in the throat of which the patient 
is constantly conscious, especially during the act of swallowing. 
Gummata in other portions of the larynx usually produce more or 
less dyspnea. The voice becomes hoarse or aphonic, the degree 
thereof depending upon the amount of interference with the move- 
ments of the vocal cords. 

During- the active stages of ulceration edema of the larynx 
may develop and evoke sufficient dyspnea to necessitate either 




Fig. 286.— Cicatricial web-formation between the vocal cords. 



scarification or tracheotomy. The vocal cords, when involved, 
show irregular changes and marked immobility. 

The sequela; of extensive necrosis mark the advent of the 
fourth stage of laryngeal syphilis — namely, scars, adhesions, and 
stenosis. Tertiary syphilis of the larynx almost invariably results 
in permanent damage to its structures. The epiglottis may become 
deformed, partially or wholly destroyed, or adherent to the sur- 
rounding structures. One or both vocal cords may be destroyed 
by the ulcerative process or become adherent to the surrounding 
tissues. In some instances they become partially attached to each 
other by means of a web of connective tissue (Fig. 286). Fixation 
of the cords may result from ankylosis of the cricoarytenoid 
cartilages. The subglottic region may become narrowed as a 
result of connective-tissue bands. 

The principal permanent results are : Dyspnea from narrow- 
ing of the calibre of the larynx, fixation or paralysis of the vocal 
cords, and loss of voice. During the stage of necrosis fetor of the 
breath is a marked symptom. 

Diagnosis. — The diagnosis is based upon ihc characteristic ap- 
pearance of the lesion, the history of syphilis and its controllability 
by antisyphilitic medications. 



444 INFLUENCE OF GENERAL DISEASES. 

Prognosis. — Gummata in acquired syphilis, when seen early, 
usually respond favorably to medication. Under early and vigor- 
ous internal treatment they disappear in from one to eight weeks. 
In neglected cases ulceration ensues with more serious results in 
the form of scars, cicatrizations, and deformities. 

Of deformities the serious types are adhesions of the soft palate 
to the posterior pharyngeal wall and those occurring within the 
larynx. In all the prognosis should be guarded, inasmuch as death 
may occur suddenly from edema or complete stenosis. In this 
type the voice usually becomes permanently impaired or aphonic. 

Treatment. — The gumma, when nodular and not ulcerating, 
requires no local treatment. At this stage it is possible by prompt 
and vigorous internal medication to effect a cure without ulceration, 
necrosis or subsequent deformity. The ulcer, when superficial, is 
benefited by the use of local cleansing alkaline washes or sprays, 
of which the physiological normal salt solution is the type, 
followed by topical applications of argyol in 25 per cent, solution, 
or silver nitrate in 5 per cent, to 10 per cent, solution. 

The A T osc. — Necrosis of the bones and cartilages of the nose 
necessitates a resort to surgical measures. The presence of 
necrosed bone is revealed by the characteristic odor and by the 
use of the probe. Before operating the location and extent of the 
necrosed area should be carefully mapped out. This procedure is 
facilitated by first packing the nasal cavities with a solution which 
contains adrenalin 1 : 5000 and cocaine 2 per cent. The adrenalin 
effects marked shrinking of the soft tissues, thus yielding a better 
view of the diseased bone, and the cocaine produces local anesthesia 
of the parts preparatory to the removal of the diseased bone and 
soft tissues. 

The Operation. — Having located the necrosed sequestrum, it is 
usually possible to accomplish its removal with forceps. When the 
necrosed masses are large it becomes necessary to incise the soft 
tissues about them in order that extraction may be effected without 
unnecessary laceration. In case the nasal bones separate and come 
away serious external deformity results (Fig. 283). 

The removal of the turbinals and vomer is less serious, while 
the loss of the entire cartilaginous septum is followed by collapse 
of the tip (Fig. 284). Even though deformities occur, it is none the 
less necessary to remove all necrosed bone and curet necrosed areas. 

Postoperative treatment consists in washing the nasal cavity 
with warm salt solution, followed by applications of argyrol in 25 
per cent, solution to the diseased areas. Healing takes place rapidly 
under vigorous internal medication. 

Treatment of the deformities of the nose when due to syphilis 
should never be attempted until the underlying disease is under full 
control. A variety of plastic operations, combined with the inser- 
tion of metal, hard-rubber and bone splints have been devised. 
The results of this form of treatment are usually unsatisfactory. 
The most effective method of overcoming these deformities is by 



SYPHILIS. 445 

paraffin injections, for a description and illustration of which see 
Chapter XL. 

The Nasopharynx and Pharynx. — The treatment of tertiary- 
syphilis of the nasopharynx is constitutional, as heretofore de- 
scribed, but in case of ulcerations every possible effort should be 
made to prevent adhesions. This may be accomplished by cauteriz- 
ing the ulcerated surface with a strong solution of nitrate of silver 
or iodin, and by keeping the surfaces clean by syringing with salt 
or other alkaline solutions. Any tendency to the formation of 
adhesions should be promptly met by separating the bands at fre- 
quent intervals. Adhesions of the soft palate with the posterior 
pharyngeal wall when already formed are most difficult to break 
down. Being usually due to the ulcerative process associated with 
tertiar}^ syphilis, with strong and inelastic new connective-tissue 
formations, they resist almost every effort to restore the normal 
functions of the nasopharynx. The clinical picture of palatal 
adhesions is variable, depending upon the site of the ulcers as well 
as the changes in the structure and shape of the velum. The 
adhesions may be partial or total, and are situated either at the 
margin of the velum or above it. The ear is almost invariably 
involved by obliteration (partial or complete) of the Eustachian 
tube. 

The treatment of deforming cicatrices in the pharynx, especially 
those of adhesions of the soft palate to the posterior pharyngeal 
wall, is invariably unsatisfactory, inasmuch as syphilitic adhesions 
consist of dense, white, tough bands which radiate in all directions 
from the centre of the original ulceration. On the posterior pharyn- 
geal wall the submucosa may be bound down to the anterior 
portion of the cervical vertebrse. To the finger the scar feels im- 
movable and hard. The least that may be expected is to maintain 
a small communication between the posterior nares and the 
pharynx. After incision through the adhesion, Coakley 2 advocates 
the introduction of a tape drawn through both the nostrils and the 
mouth, the ends to be tied so as to keep the incised edges apart. 

The Larynx. — Owing to the slight discomfort induced by 
gummata in this region, the surgeon is seldom consulted until 
the stage of ulceration. The ulcerative stage threatens serious 
consequences in the form of permanent loss of the voice, and laryn- 
geal stenosis. It therefore becomes imperative that the internal 
medication be rapidly pushed to its physiological limits in order 
to prevent these serious sequelae. 

Locally, soothing sprays and applications for the relief of 
cough and pain often become necessary. Mild attacks of perichon- 
dritis of the laryngeal cartilages often resolve under internal 
medication, without necrosis. 

Should necrosis intervene it becomes necessary to remove the 
diseased areas. Such operations may be performed either with 



Diseases of the Nose and Throat. 



445 INFLUENCE OF GENERAL DISEASES. 

indirect illumination or, preferably, by direct laryngoscopy (see 
Chapter LIU). 

The advent of dyspnea during the course of tertiary laryngeal 
syphilis is of serious import. When due to the location or size 
of a gumma the patient should remain quiet until the mass subsides 
as the result of general treatment. Edema developing during the 
stage of ulceration which does not produce urgent symptoms often 
subsides upon scarification of the tissues. The laryngeal mucosa 
should first be anesthetized by spraying with a solution of cocaine, 
after which several incisions may be made into the edematous 
portions by means of a guarded knifeblade (Fig. 495). 

Exudation immediately follows, which may be prolonged by 
steam inhalations. If the dyspnea increases notwithstanding the 
scarification, tracheotomy should be performed without delay. In 
some instances the dyspnea is caused by the dislodgment of 
sequestra into the lumen of the larynx, and the resultant urgent 
symptoms require removal by laryngoscopy or laryngotomy. The 
surgical treatment of laryngeal stenosis and adhesions is fully 
described in Chapter XLIX. 

D. CONGENITAL SYPHILIS. 
Secondary Lesions. 

Etiology. — In the secondary form congenital syphilis of the 
nose, throat, and larynx usually appears during the first few weeks 
of life in the form of erythema or mucous patches, which are pre- 
cisely the same as those of acquired syphilis. 

Symptoms. — The chief symptom is nasal discharge and occlu- 
sion, with snuffling, snoring, and mouth breathing. The child can 
take the breast or bottle for only a few seconds at a time. He 
emaciates rapidly and becomes wrinkled and weazened in ap- 
pearance. 

In the pharynx and larynx the disease produces a hoarse cry, 
which is quite characteristic and suggests infiltration in the larynx. 
Gaucher claims congenital syphilis as a causative factor in hyper- 
plasia of the pharyngeal tonsil. Glandular hypertrophy and the 
typical skin eruptions aid in confirming the diagnosis. 

Tertiary Lesions. 

The tertiary form of congenital syphilis commonly appears 
from 7 to 14 years of age. The range may be from 4 to 20 years. 
Typical gummata and ulcerations develop the same as in acquired 
syphilis. 

The Ear. — Congenital tertiary syphilis, when it involves any 
portion of the auditory apparatus and especially the labyrinth or 
auditory nerve trunk, produces serious and sometimes permanent 
impairment of the hearing function, and in many cases marked 
nystagmus and vertigo. The following case furnishes an illus- 
tration : — 



SYPHILIS. 447 

H. D., female, aged 16 years. Father healthy, but mother had con- 
tracted syphilis six months previous to her marriage. The mother had nine 
pregnancies and five miscarriages, five of which occurred prior to the birth 
of the patient. The child had blisters on the sides of her feet when born, 
but otherwise had remained well since childhood, except for a spontaneous 
nystagmus and some disturbance of equilibrium. She is well developed 
physically, but somewhat backward mentally. Her nasal respiration has 
always been somewhat impaired, owing to a septal spur, adenoids and hyper- 
trophied tonsils. There had been no perceptible impairment of her hearing. 
On November 4, 1909, upon awakening, she complained of pain in her right 
knee and foot, and that she could not hear. She had intense tinnitus and 
marked vertigo. The right knee was swollen and painful to the touch, and 
there was considerable muscular weakness of the right arm and leg. Her 
reflexes were exaggerated. When standing with the eyes closed she swayed 
to the left, but felt as though falling to the right side. An examination of 
the pharynx revealed absence of the uvula and a partial adhesion of the soft 
palate to the posterior pharyngeal wall. 

The right membrana tympani was retracted and the left inflamed. 

Functional Tests. — Weber test was heard to the right. When Barany's 
noise-producer apparatus was applied to the right ear, neither loud voice 
nor tuning fork heard, showing total deafness in left. 

Caloric Test. — Irrigation with cold and hot water showed no reaction 
in left ear. The Wassermann test, made some time after the commencement 
of specific treatment, was negative. 

The patient was admitted to the Post-graduate Hospital on November 
26th. She then had marked arthritis of the right knee and ankle, which 
soon extended to the left knee and ankle. The joints were swollen, painful 
and tender. She had a temperature ranging from 101° to 104° for about a 
week, when it became normal and remained so. There was a partial anky- 
losis of both knee-joints, which was overcome by heat, massage and passive 
movements. She was given the usual antispecific treatment, and she rapidly 
improved. January 7th she was discharged and taken to her home. Soon 
afterward she developed an interstitial keratitis in the right eye. The iodid 
of potassium was rapidly increased up to 120 grains three times per day. 

The loss of hearing has remained permanent. She still suffers some- 
what from vertigo and has repeated attacks of keratitis in both eyes, but 
the joints have cleared up and she is able to walk about and attend to her 
duties. 

In the larynx of the infant the chief symptoms are bleating or 
almost voiceless crying, and cough which is lacking in tone. 
Dyspnea is present and commonly accompanied by laryngismus 
stridulus. Edema and dysphagia are common. Hutchinson's teeth 
are found in older children. Postmortem examinations have shown 
that necrosis of the laryngeal cartilages does occur in syphilitic 
infants. 

Prognosis. — Under two years of age the disease is very grave, 
few cases surviving. Death occurs from asphyxia, starvation, mal- 
nutrition or bronchopneumonia. Older children may becdme 
victims of the various forms of laryngeal deformities. 

Treatment. — The treatment is the same as in acquired forms. 

E. SYPHILIS OF THE ACCESSORY SINUSES. 

Tertiary syphilitic bone necrosis of the accessory sinuses is 
occasionally observed, usually attacking the frontal and ethmoidal 
cavities first, and later the antrum of Highmore and the sphenoidal. 
Gummata invariably originate in the bone and not in the mucosa. 



448 INFLUENCE OF GENERAL DISEASES. 

Leucoplakia Oris. 

Leucoplakia oris, sometimes known as psoriasis buccalis, is an 
oral disorder which may affect the entire mouth, but is usually most 
marked in the anterior portions. The usual site is upon the anterior 
half of the surface of the tongue and along its margin, although 
the mucous membrane of the lips, angle of the mouth and cheeks 
are sometimes covered by these bluish-white, white, opaline or 
somewhat yellowish patches ; in addition to the smooth patches, 
either shining and moist or dull and dry, the tongue often shows 
small cracks and minute ulcers. 

The pathology consists in passive hyperemia and round-celled 
infiltration of the mucosa due to the presence of inflammatory irri- 
tation. The covering of the patches is made up mostly of hyper- 
plasia and hyperkeratosis of the epithelium. 

The main etiological factor is syphilis; here leucoplakia shows 
itself in the recently infected cases. W. Erb found a clear history 
of syphilis in < c per cent, of his cases. The condition, however, is 
aggravated and prolonged by gastric catarrh, excessive smoking 
and by nasal secretions, both catarrhal and purulent. It is con- 
sidered more significant when occurring upon the tongue, many 
authorities believing that the epithelial proliferation has a tendency 
to degenerate into cancer. 

There are no distressing symptoms, only slight pain being 
experienced at the seat of the lesions. 

The treatment is chiefly local ; yet, in some cases, tonic, anti- 
luetic or other constitutional treatment must be resorted to. Locally 
Leistikow uses the following paste: Resorcin, 6 parts; terrae siliceae, 
3 parts; lard, 1 part; this is applied over the patches with a swab after 
eating and before going to bed. In a week or two the patches are said 
to disappear. Rinsing the mouth frequently with an alkaline .wash is 
useful, and, to overcome the hyperemia caused by the resorcin, ap- 
plications of balsam of Peru are recommended. 

In obstinate cases Rosenberg has had excellent results by the 
local application of a 20 per cent, solution of iodid of potassium. 

To avoid the evolution of this disease into true cancer Perrin 
completely extirpates the spots or patches by surgical means. 



CHAPTER XXXI. 

THE INFLUENCE OF GENERAL DISEASES UPON THE 

EAR, NOSE AND THROAT. 

(Continued.) 



DIPHTHERIA. 

General Remarks. — Diphtheria is an acute contagious disease, 
characterized by fibrinous exudate which is produced by the Klebs- 
Loeffler bacillus. The exudate occurs most frequently on the 
tonsils, soft palate, accessory sinuses and larynx, and rarely in the 
middle ear or external auditory canal. In severe cases the mem- 
brane extends in all directions, occasionally involving the con- 
tiguous skin. The disease rarely occurs primarily in the external 
auditory canal. 

Etiology. — It is essentially a disease of childhood, occurring 
chiefly from the second to the fifteenth year, the proportion being 
larger from the second to the fifth. Inflammatory enlargement of 
the glands composing the lymphoid ring, disease of the mucosa of 
the nose, throat, and mouth, and lowered conditions of general nutri- 
tion are predisposing factors. The specific cause of the disease is 
the Klebs-Loeffler bacillus (Fig. 287). In New York City it is 
most prevalent between October and March. The disease is 
universal both as to race and locality, but is more prevalent among 
poorly nourished children in overcrowded tenements. Sunshine, 
fresh air and good sanitation are foes to the diphtheria bacillus. 

The scarlatinal sore throat is usually susceptible to the Klebs- 
Loeffler bacillus, which is very hardy and capable of living many 
months outside the body. 

Mode of Infection. — Infection often takes place through clothes, 
instruments and utensils, in which the germ may live many months. 
Likewise it persists in the nose, throat and mouth long after the 
disease has disappeared and with little, if any, decrease in virulency. 
The infection is transmitted by towels, napkins, clothing, bedding, 
books, rugs, wall paper, and cooking utensils in use about diph- 
theritic patients, and may be conveyed by naturally immune attend- 
ants. Infection may thus contaminate the milk supply and cause 
the disease in cats and dogs as well as in individuals. The disease 
is directly conveyed by kissing, inhaling directly from the diph- 
theritic any mucus or floating particles of infection. Solis-Cohen 
reports 27 cases of latent diphtheria with mild symptoms of tonsilli- 
tis and pharyngitis. It occurs with greater frequency through con- 
taminated food than through inspired air. Diphtheria appears 
either in epidemic, endemic or sporadic form, and always with vary- 
ing severity. The incubation period varies from twenty-four hours 
to a week — usually from three to four days. 

29 (449) 



450 INFLUENCE OF GENERAL DISEASES. 

Pathology. — The onset of the disease is characterized by 
hyperemia and round-cell infiltration in the mucous membrane and 
by the transudation of lymph. The characteristic diphtheritic mem- 
brane is the result of coagulation necrosis of the epithelial layer of 
the mucous membrane, which is produced by the toxins. The diph- 
theritic membrane ordinarily extends to the submucous layer, and 
only in severe cases does it reach the underlying tissue. The 
coagulation of lymph into fibrin makes the false membrane very 
firm and tenacious, and the exudate causes the membrane to be 
raised above the surrounding level. 

The color of the membrane ranges from a dirty gray when 
superficial to a dark green or black when the deep blood-vessels 
become involved, thus cutting off nutrition and by so doing pro- 




Fig. 287. — Diphtheria or Klebs-Loeffler bacilli. Smear deposit. 
Loeffler's stain. (Lenhartz-Brooks.) 

ducing gangrene. A line of demarkation appears in from four to 
six days; the fibrin becomes granular; epithelial cells disintegrate, 
and the membrane separates in large or small pieces. If the 
involvement is deep an ulcerating surface is left. There is more 
or less cervical adenitis. 

Antitoxin possesses the power to cut short the membranous 
proliferation. There is usually no extension of the diphtheritic 
membrane after twelve hours from the time of injecting antitoxin, 
and as a rule the membranous exudate disappears entirely in from 
thirty-six to forty-eight hours after an injection of antitoxin. 

Types of the Disease. — (a) Non-membranous, in which there is 
redness and infiltration of the mucosa but no membranous exudate. 
The Klebs-Loeffler bacilli are present in the secretions. 

(b) Fibrinous (Monti). — The microscopic findings show the 
Klebs-Loeffler bacilli in pure culture unmixed with other patho- 
genic organisms. The membranous exudate may be localized or 
diffuse, and the toxemia mild or severe. 



DIPHTHERIA. 451 

(c) Mixed Infections (Monti). — In this type there is severe 
inflammation of the submucosa, which tends to necrosis of the 
tissues, the formation of phlegmon, gangrene and other severe 
manifestations, all resulting from the combined action of the toxins 
of the Klebs-Loeffler bacillus and other pathogenic organisms, 
notably the streptococci. 

DIPHTHERIA OF THE EAR. 

Etiology. — Primary diphtheria of the ear is very rare. Otitis 
media purulenta acuta occurs in 10 per cent, of all cases of diph- 
theria (Duel), and it shows a marked tendency to become chronic. 
When the purulent otitis continues during convalescence from 
diphtheria the Klebs-Loeffler bacilli are generally associated with 
streptococci. The involvement of the ear is more frequent in the 
malignant and fatal forms of the disease. In the latter a normal 
tympanum is seldom found. In 25 fatal cases only 1 had a normal 
ear (Siebenmann). The disease usually comes on at the height of 
the nasopharyngeal process, and the infective bacteria probably 
enter the tympanic cavity through the Eustachian tube. Diph- 
theritic bacilli, once in the ear, are liable to remain for a long time, 
but they lose much of their virulence after the subsidence of the 
acute symptoms. 

Symptoms. — Otalgia is severe and tends to remain several days 
after perforation of the membrana tympani. Perforation of the 
drum is very rapid, more rapid than in the ordinary acute purulent 
cases, and the temperature rise is higher. In very young children 
cerebral symptoms, delirium and convulsions may occur at the 
onset. Enlarged cervical lymph glands are more common than in 
ordinary purulent otitis media. The rapid destruction of the drum 
is due to the toxic necrosis induced by the specific bacteria, which 
are conducive to rapid destruction of these tissues. Occasionally, 
the characteristic membrane may be visible in the middle ear, and 
extends outward into the external auditory canal. It can be 
removed only with force, leaving a bleeding surface. The dis- 
charge is slight during the first few days, but, as the membrane 
separates, it becomes profuse, foul, and sometimes bloody. The 
mucous membrane of the tympanum becomes swollen, red and 
edematous. Mastoiditis and other serious complications are com- 
paratively common in diphtheritic otitis media. 

Prognosis. — The suppuration is prone to persist and to become 
chronic unless terminated by appropriate treatment. Large, per- 
manent perforations in the drum usually result, through which 
granulations and polypi may protrude. The suppuration sometimes 
becomes chronic, with resultant bone necrosis. 

Deafness is marked during the acute stage, but improves as 
the disease subsides. There is usually a moderate residual deaf- 
ness. Partial or total deafness remains when the labyrinth has 
been seriously involved, and when occurring in infants deaf-mutism 
may thus result. Combined with scarlatina the process is usually 
more destructive and the involvement more extensive. 



452 INFLUENCE OF GENERAL DISEASES. 

Treatment. — Aside from the usual antitoxin and general meas- 
ures of treatment, thorough paracentesis should he performed at 
the first sign of tympanic pain. Otherwise the treatment is the 
same as in ordinary cases of otitis media purulenta acuta. An im- 
portant prophylactic measure consists in cleansing the nose and 
throat from the onset of the diphtheritic attack with hot normal 
sail solution, as frequently as is necessary to keep the surfaces clean. 
This will often prevent the extension of the process much beyond 
the original seat vi the disease. 



DIPHTHERIA OF THE NOSE, THROAT AND LARYNX. 

Symptoms. — There are both local and constitutional symptoms, 
the latter, evidently, arising from the effect of the toxins in the 
general circulation. Among the constitutional symptoms fever, 
muscular weakness, and depression are prominent. The onset of 
the disease is characterized by general malaise, loss of appetite, and, 
sometimes, vomiting. Convulsions sometimes occur in infants, 
while older children and adults do not complain until the sensation 
of soreness and stiffness appears at the site of the exudate. The 
temperature varies from 101° to 104° during the first three or four 
days, during which time the pulse is usually accelerated. 

During the later stages the pulse may become slow, irregular 
or intermittent, on account of cardiac weakness. 

In severe forms there is a great prostration, delirium, extremely 
foul odor, dark complexion, extensive cervical adenitis, and death 
may ensue as early as the second day. 

The most serious complications are cervical adenitis, myo- 
carditis, endocarditis, nephritis, purulent otitis media and laryngeal 
stenosis. 

Locally there are pain and soreness around the inflamed mucous 
areas and evidences of mechanical obstruction to nasal and laryn- 
geal respiration due to the exudate. The odor from the mem- 
branous exudate is foul and quite characteristic. 

Nasal Diphtheria. 

Diphtheria of the nose rarely occurs unaccompanied by pharyn- 
geal manifestations. The symptoms peculiar to nasal diphtheria 
are as follows : At the onset there is a profuse discharge of muco- 
pus, which produces excoriation about the nostrils. This symptom, 
occurring suddenly in young children, should arouse suspicion, and 
a test culture should be taken. 

Upon examination the characteristic membranous exudate will 
be found upon the septum or turbinate, and as the disease pro- 
gresses the discharge becomes blood-tinged and epistaxis may take 
place. There is a tendency to mouth breathing and the breath is 
foul. The constitutional symptoms are mild if the anterior portion 
of the nose alone is involved. Cervical adenitis is common. The 
membrane may completely fill the nostril, and spread over the 



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FIGURE 288. 

Case A. — Common Type of Diphtheria. Child three years old. Seen 
on fourth day of illness at the Willard Parker Hospital. Exudate covering 
tonsils, pharynx, and uvula. Received in all 16,000 units of antitoxin. 
Throat clear on sixth day. Case discharged cured. (Original.) 



Case B. — Follicular -Type of Diphtheria. Child _ seven years old. 
Seen on second day of illness at the Willard Parker Hospital. The mem- 
brane involved the lacunae of the tonsils. Note the close resemblance to 
follicular tonsillitis. Received in all 6000 units of antitoxin. (Original.) 



Case C. — Hemorrhagic Type of Diphtheria. Child seven and one- 
half years old. Seen on sixth day of illness at the Willard Parker Hospital. 
Tonsillar and postpharyngeal exudate. Severe nasal and postpharyngeal 
hemorrhages during exfoliation of membrane. Received in all 15,000 units 
of antitoxin. Throat clear on ninth day of illness. Myocarditis developed. 
Case discharged cured four week's after admission. (Original.) 



Case D. — Septic Type of Diphtheria. Child eight years old. Seen 
on the fifth day of illness at the Willard Parker Hospital. The pseudo- 
membrane in this case covered the hard palate and extended in one large 
mass down the pharynx, completely hiding the tonsils. (Original.) 



(Fischer, with permission.) 




A 


«* 








,1^^^^ 


. 


Ml 








Fig. 288. 



DIPHTHERIA. • 453 

septum and inferior turbinal. As this separates, complete casts of 
the interior of the nose may be discharged. An ulcer is often left 
behind. Middle-ear suppuration is a common complication of nasal 
diphtheria. 

Pharyngeal Diphtheria. 

As a rule, the diphtheritic membrane develops primarily upon 
the tonsils and extends by contiguity to the uvula, soft palate, and 
posterior pharyngeal wall. Patients having adenoids and diseased 
tonsils are not only more liable to the disease, but the attacks are 
severer and complications are more frequent. 

Examination. — A thin, grayish membrane, either circumscribed 
or in patches, appears upon the tonsil, pillars, soft palate, or 
posterior pharyngeal wall (Fig. 288). The false membrane grad- 
ually becomes thicker and hence elevated above the surrounding 
membrane. The patch is surrounded by a narrow, dark, hyperemic 
zone, and during the early stages it may be mistaken for lacunar 
tonsillitis. It is removed with difficulty, and a bleeding surface 
remains. The exudate re-forms rapidly. 

When gangrenous, the exudate becomes greenish or black. 
Without antitoxin the membrane disappears in from five to twelve 
days. The edges gradually separate and curl up and large pieces 
break away, leaving ulcers. In every suspected case a culture 
should be taken from the secretions of the diseased area for 
laboratory examination. 

Laryngeal Diphtheria. 

Laryngeal diphtheria usually occurs as a secondary manifesta- 
tion of either the nasal or pharyngeal types, and is characterized by 
a dry,, croupy cough and a hoarse voice. In severe cases, with 
extensive areas of exudate, dyspnea rapidly ensues, the voice is lost, 
and impeded or stridulous respiration is observed. This is accom- 
panied by extreme restlessness, tenseness of the sternocleido- 
mastoids, retraction above and below the clavicles and of the 
diaphragmatic portions of the chest during inspiration and cyanosis 
unless relief is obtained, otherwise a fatal issue ensues. 

In favorable cases the membrane is circumscribed and remains 
so until it gradually exfoliates. The disappearance of the exudate 
marks the gradual subsidence of the laryngeal symptoms. 

Differential Diagnosis. — Streptococcic tonsillitis is common in 
scarlet fever, measles and other infections. The exudate in these 
cases tends to coalesce and form a membrane which in appearance 
is similar to that of diphtheria. Bacteriological diagnosis often 
becomes the sole criterion. 

The mucous patch of syphilis differs from diphtheritic exudate 
as follows: It is thin, non-adherent, with slight or no elevation 
above the surrounding mucosa. Its duration is without definite 
limitations, there is lack of acute constitutional symptoms, and 
there is the added presence of other specific symptoms of syphilis. 



454 • INFLUENCE OF GENERAL DISEASES. 

Pharyngeal mycosis differs from diphtheria by being a non- 
inflammatory condition, with no constitutional symptoms. The 
conical projections are characteristic. On examination with the 
microscope the Mycelium leptothrix buccalis is found. 

. Prognosis. — In uncomplicated nasal and pharyngeal diphtheria 
in patients subjected to antitoxin during the first three days the 
prognosis is good, the death rate not exceeding 4 to 10 per cent. 
Mild cases may suddenly become virulent, or fatal complications 
may quickly terminate in death. 

The prognosis is influenced by the character of the epidemic, 
the prevailing type of the disease, the condition and surroundings 
of the patient, the age of the patient, the laryngeal type, and by 
such complications as glandular involvement, cardiac failure, epis- 
taxis, gangrene, and bronchopneumonia. 

TREATMENT OF DIPHTHERIA. 

The treatment of diphtheria is considered under four headings: 
1, prophylactic; 2, hygienic and dietetic; 3, constitutional; 4, local. 

Prophylactic. — The virulence of the diphtheritic bacillus has 
become well known as a result of the bacteriological studies of 
recent years. The Klebs-Loeffler bacillus is found in the upper air 
passages for long periods after all constitutional symptoms of the 
disease have passed away. Nurses and other attendants of diph- 
theritic patients may likewise convey the germs without constitu- 
tional or marked local symptoms of the disease. Prophylaxis, there- 
fore, becomes an important phase in the treatment. 

Isolation is the key to this situation. Diphtheria patients 
should remain in quarantine until the cultures no longer show the 
specific bacilli, in order to prevent the spread of the disease. 
Immunization is now a recognized preventive measure. Immuniza- 
tion doses of antitoxin are now administered to members of the 
family, nurses or other attendants who have been in close contact 
with the victim of the disease. An outbreak of diphtheria in a 
hospital ward, asylum or schoolroom calls for the removal of the 
patient, the segregation of all who have been exposed, and mean- 
while the entire number should receive immunizing injections of 
from 50 to 500 units of antitoxin, according to age. The ward or 
schoolroom, including all utensils, bedding, clothing, books, etc., 
should be fumigated according to the methods hereinafter described 
under the heading "Hygienic Treatment." 

Inasmuch as the nasopharynx is often the seat of hypertrophied 
tonsils and adenoids, which predispose to attacks of diphtheria on 
account of the admirable soil which they furnish for the growth of 
the Klebs-Loeffler bacilli, it is a wise precaution, as a preventive 
measure, to have them removed at the proper time (Chapters XLIII, 
XL VI), but never during any period when the nasopharyngeal 
tissue is the seat of infection. 

Nurses and attendants of diphtheritic patients should make 
frequent use of sprays or gargles of normal salt solution or dilute 



DIPHTHERIA. 455 

alcohol, in order to remove all retained infective secretions. In the 
throat 1 : 5000 solution of bichlorid of mercury may have some 
bactericidal effect, providing care is used not to swallow the fluid. 

Hygienic and Dietetic Treatment. — The diphtheritic patient 
should, whenever possible, be placed in a large, well-ventilated 
room that is free from unnecessary drafts. A constant and liberal 
supply of fresh air is a valuable adjunct in the treatment of this 
disease. Floor coverings, books, pictures and all other movable 
articles which are not needed are to be removed. The temperature 
should be maintained at from 66° to 72°. A constant flow of steam 
from a croup kettle serves to keep the air moist. 

Small squares of gauze or pieces of old cotton or linen which 
may be immediately burned should be substituted for handkerchiefs 
for the reception of all discharges from the nose and throat. All 
nightgowns, towels, and bedlinen should be immersed in a solution 
composed of 6 ounces of carbolic acid to 2 gallons of hot water, and 
then boiled in soapsuds for one hour. All patients with diphtheria 
should be given 'a. sponge bath with tepid water twice a day, after 
which the body should be rubbed briskly with alcohol. The hands 
of the attendants and physicians should be thoroughly scrubbed 
with green soap and afterward immersed in a bichlorid of mercury 
solution 1 : 1000. 

The table utensils used by the patient are to remain in the sick- 
room and be washed in a carbolic solution and then in soapsuds. 
The attending physician and nurses should protect their clothing 
by wearing long gowns kept just outside the patient's room. After 
convalescence the patient should receive a hot soapsuds bath, in- 
cluding the hair and scalp, and all contaminated clothing exchanged 
for fresh garments. The room should then be turned over to the 
health authorities for disinfection, according to approved methods. 

Dietetic. — It is of the utmost importance to maintain the 
tissues of the body by proper food. Any food which may be easily 
digested and assimilated is admissible to the diphtheritic patient. 
Peptonized milk stands at the head of the list of nutritive foods for 
diphtheritic patients. It may be diluted with thoroughly cooked 
oatmeal, barley, or rice. Older children may occasionally take a 
raw egg beaten up in milk. Buttermilk and zoolak are nutritive 
and easily assimilated. Animal broths may be substituted when- 
ever milk is not well borne, or administered as a change of diet. 
Acid fruits, oranges, grapes, lemons and cranberries are usually 
well borne. It is sometimes necessary to resort to rectal feeding 
where intubation has been performed, and the following formula is 
recommended : Peptonized milk, 1 ounce ; laudanum, 1 cubic 
millimetre. To this may be added the yolk of a raw egg if desired. 

Constitutional Treatment. — The antitoxin treatment -of diph- 
theria has long since passed the stage of experiment, and, therefore, 
no longer needs defense. It is most effective when administered 
during the early stages of the disease — that is, before the end of the 
third day. A favored method of administration is by hypodermic, 
although it has been made use of per os and per rectum. Hypo- 



456 INFLUENCE OF GENERAL DISEASES. 

dermatically, it is now administered by means of a special syringe, 
the glass barrel of which contains the dose of antitoxin, great care 
being exercised in sterilizing the syringe, needle, the skin of the 
patient and the physician's hands. In this manner secondary 
abscess formations at the seat of the puncture are prevented. 

The following (Fig. 289) is a copy of the printed directions 
and cut of the syringe which is furnished by the health department 
of the City of New York : — 



Fig. 289. — Antitoxin syringe. 

Site of Injection. — A portion of the body is generally selected where 
there is much loose subcutaneous tissue, and the injection made directly 
under the skin. The region of the back on either side below the scapula 
and above the border of the ilium offers possibly the best site. The skin 
should be thoroughly washed with soap and water, afterward with a dis- 
infectant, and last with alcohol. 

Directions for Operating Syringe. — After preparing the site on the 
patient for injection, remove paper wrapping from short end of needle 
(leaving the long end of the needle wrapped for protection) and force 
the short end through rubber stopper of the syringe to the hub. Then 
remove wire and paper wrapping from long end of needle, and, holding 
the syringe in a perpendicular position with needle elevated, expel the air. 
The syringe is then ready for the operation, all parts of it having been 
thoroughly sterilized in the laboratory. 

The Dose Required. — The dose of antitoxin depends upon the 
severity of the attack and the age of the patient. Children from one 
to five years of age usually require a primary dose of from 1500 
to 3000 units. Older children should receive from 3000 to 5000 
units, and, in unusually severe toxemic cases with extensive pseudo- 
membrane and cervical lymph gland enlargement, an initial dose of 
10.000 units may be injected. Visible improvement is indicated 
by the sloughing of the pseudomembrane, improvement in appear- 
ance and appetite, and lower temperature. Whenever no such 
improvement takes place after from twelve to twenty-four hours, a 
second but minimum dose should be administered. Free purgation 
at the commencement of the disease either with castor-oil or 
calomel is favored. 

The antitoxin treatment is more favorable when only the Klebs- 
Loeffler infection is present. Mixed infections are less amenable to 
its effects. Marked streptococcemia in addition to general diph- 
theria creates an unfavorable prognosis, inasmuch as the antitoxin 
produces no effect upon the streptococcic invasion. 

It is important to closely watch the condition of the heart as 
evinced by the pulse during the course of an attack of diphtheria. 
Evidences of cardiac weakness may appear at any time. The pulse 
may be either rapid, irregular, intermittent or unduly slow, the 



DIPHTHERIA. 



457 



latter being the most common. At the first sign of heart-failure, all 
unnecessary exertion on the part of the patient should be inter- 
dicted. He should remain in bed and not be allowed to rise for any 
purpose, and all excitement avoided. The diphtheritic toxins tend 
to produce a depressing effect upon the heart. Stimulants, there- 
fore, should be commenced upon the first evidence of cardiac weak- 
ness. Whiskey and strychnia are the remedies commonly employed 
for this purpose. They are well borne both by children and adults. 
From 30 drops to 2 teaspoonfuls of whiskey, and from % o to % 




Fig. 290. — Method of nasal syringing employed in the contagious 
cases of the Riverside Hospital. (Fischer.) 



of a grain of strychnia, according to the patient's age, is the proper 
dosage. Tokay wine, champagne and coffee are often well borne. 

Treatment of the postdiphtheritic paralysis consists in the 
administration of small doses of strychnia, forced nutrition and 
moderate exercise in the open air. This form of paralysis is self- 
limited, but a cure is hastened by these measures. Nephritis and 
cardiac complications should receive the skilled treatment of 
internal medicine practitioners. 

Local Treatment, (a) Nasal Diphtheria. — In addition to meas- 
ures employed for the general elimination of the toxic elements of 
the disease through the bowels, kidneys, and skin, local measures 
prove most beneficial. It is important to remove all surplus secre- 
tion from the nasal cavity at frequent intervals, for the purpose of 



458 



INFLUENCE OF GENERAL DISEASES. 



maintaining nasal respiration, and, further, to remove all retained 
toxic elements, which are commonly associated with the Klebs-« 
Loeffler bacillus in the nasal cavity. The diphtheritic membrane is 
not easily removed, and undue force should never be employed for 
this purpose. AYhenever it is thought necessary to remove the 
accumulated exudate from the nose it should be done by means of 
the douche bag in the following manner (Fig. 290) : — 

The child is first wrapped in a blanket with the arms so pinned 
that struggle is impossible, and is then laid upon the side with the 
head slightly lower than the body. Employing a 2-quart fountain 
svrinsje with a gflass or hard-rubber nozzle and filled with a normal 




Fig. 291. — O'Dwyer's set of intubation instruments. 



salt solution, or Yz per cent, solution of permanganate of potash, at 
about 115° temperature, the upper nostril is thoroughly washed, 
by raising the bag from 1 to 5 feet above the child's head. Follow- 
ing this suggestion in detail, the solution, instead of running into 
the nasopharynx, flows out through the opposite nostril. The 
procedure is then repeated upon the opposite side, after reversing 
the position of the child. In severe cases the nasal cavities should 
be douched from four to eight times a day. Unless previously 
trained to the use of sprays, the child will rebel during the first few 
treatments, but finally submits with good grace. 

(b) Pharyngeal Diphtheria. — The forcible removal of the diph- 
theritic membrane from the oropharynx is a harmful measure. In 
all cases, especially the severe types which are characterized by 
extensive exudate with retained secretions and mixed infection, 



DIPHTHERIA. 459 

much relief is obtained by washing- the surfaces with hot saline 
solution. Here, also, the douche is more efficacious than the spray 
or gargle. The same solutions may be employed and in the same 
manner as shown in the previous paragraph and illustrated in Fig. 
290, except that the mouth should be widely opened and the fluid 
allowed to thoroughly wash the oropharyngeal surfaces. A tract- 
able child, lying on the side with the mouth wide open, often even 
without the aid of a tongue depressor, submits to thorough washing 
of the oropharynx by the above method. 

In the treatment of obstreperous patients, who resist all efforts 
to douche or swab the throat, it is wiser to abandon these local 
measures than to persist at the expense of exhaustion or undue 
strain upon the heart. Of the so-called solvents of the diphtheritic 
membrane none have any marked effect. There seems to be some 
efficacy in steaming the nose and nasopharynx with a 2 per cent, 
sulphurous acid solution. 




Fig. 292. — The mummy bandage, showing child in proper position 
for the dorsal method of intubation. All instruments required are care- 
fully arranged. (Fischer.) 

It is generally conceded that the local measures above de- 
scribed, whereby the septic secretions are promptly removed from 
the nose and nasopharynx, serve to minimize the tendency to 
toxemia and to lymphadenitis. 

(c) Laryngeal Type. — At the onset of an attack of laryngeal 
diphtheria the patient should be subjected to the continuous use 
of steam inhalations by being placed under a tent erected over the 
bed or cot, underneath which a croup kettle is kept boiling. Marked 
relief is sometimes obtained by fumigating 10 grains of calomel 
underneath the tent. Emetics are to be avoided when the heart 
action is weak. In mild cases which are early submitted to the 
antitoxin and steam inhalation treatment the membrane exfoliates 
without serious symptoms of obstructed respiration. 

The early administration of antitoxin lias largely reduced the 
mortality from laryngeal diphtheria, and minimized the proportion 
of cases requiring intubation or tracheotomy. For the relief of 
laryngeal stenosis induced by diphtheria, intubation as devised by 



460 



INFLUENCE OF GENERAL DISEASES. 



the late Joseph O'Dwyer has largely superseded tracheotomy, the 
latter being employed only when intubation tubes are not at hand, 
when the laryngeal edema is widespread, and in cases of mem- 
branous exudate in the lower tracheal tract. 

Intubation. — Intubation is employed for the relief of laryngeal 
stenosis, the chief symptoms of which are obstructed breathing, 
cyanosis, retraction at the clavicles and epigastrium, and failing 
pulse. The indications for intubation according to O'Dwyer are 
"marked by a more or less sinking in of the yielding portions of the 
chest, lower ribs and sternum, episternal notch and supraclavicular 




Fig. 293. — Intubation. First step. Index finger raising the tip of the epiglottis. 
The tube guided along the finger. Original. (Fischer.) 



regions during inspiration. Recessions at the root of the neck are 
more significant than those below, as violent contractions of the 
diaphragm aid in drawing in the free border of the ribs and 
sternum." "Abiding cyanosis is too late a symptom to wait for." 
"Children sometimes remain long in one position when suffering 
severely from want of breath, and continued restlessness, if con- 
sciousness be unimpaired is, therefore, an important indication that 
it is time to afford relief." 

O'Dwyer's set of intubation tubes (see Fig. 291) and acces- 
sories are necessary for the performance of intubation, the sizes 
of the intubation tubes being given according to a scale of ages. 
The operation is performed either by the dorsal method or upright 



DIPHTHERIA. 



461 



method, the former being employed by the attendants at the Willard 
Parker Hospital, of New York City. The dorsal method of intuba- 
tion possesses the advantage of requiring less assistance, and at the 
same time being more available in emergencies. 

The child is placed flat upon the back (Fig. 292), the arms and 
legs being firmly held in place by wrapping in a blanket. A mouth 
gag is inserted between the jaws on the left side, and the nurse 
holds the head firmly. The operator stands upon the patient's right 




294. — Intubation. The tube passing the epiglottis. Entering 
the larynx. Original. (Fischer.) 



side and introduces the left forefinger until able to elevate and fix 
the epiglottis (Fig. 293). It now becomes a simple procedure to 
introduce the tube with the right hand and insert it into the interior 
of the larynx (Fig. 294). A partial description quoted from 
O'Dwyer's method in the upright position is herewith appended. 
The nurse is seated on a low, straight-backed chair, and the 
patient's arms secured to his side by a sheet passed around the 
body. He is placed on the lap, with the head resting on the left 
shoulder of the nurse. The gag is then inserted well back between 
the teeth and the left angle of the mouth and opened widely. An 
assistant stands behind the patient and holds the head firmly by 



462 



INFLUENCE OF GENERAL DISEASES. 



placing one hand at either side, and at the same time slightly 
elevates the chin. The operator stands in front of the patient, 
holding the introducer in the right hand, the thumb resting just 
behind the knob that serves to detach the tube. The index finger 
of the left hand is carried well down in the pharynx in a median 
line, raising and fixing the epiglottis, while the tube is carried along 
the side into the larynx. The distal extremity of the tube should 
be kept in contact with the finger and even striking it a little 
obliquely toward the right side of the larynx if necessary to get 
inside the left aryepiglottic fold, especially in young children. As 




Fig. 295. — Casselberry method of feeding. (Fischer.) 



soon as the cannula is inserted, the introducer, with obturator 
attached, is withdrawn by pressing forward the button on the upper 
surface while counterpressure is made with the index finger on the 
trigger beneath. To prevent the tube from being also withdrawn 
the left finger must be kept in contact with its left shoulder. The 
tube should be carried well down in the larynx before detaching. 
The gag is removed as soon as the tube is in place, but the string 
is allowed to remain in place until certain that dyspnea is relieved. 
In removing the string the finger must be reinserted to hold the 
tube down. A characteristic cough follows immediately whenever 
the tube has been properly inserted, and during the paroxysm 
mucus and mucopus are freely expelled. The most marked indica- 



DIPHTHERIA. 



463 



tion that the tube has been properly inserted is found in the almost 
instantaneous relief of all symptoms of stenosis. 

The introduction of the tube should invariably be performed 
without the employment of any force whatever. Quick intubation 
requires that the operator make certain of the position of the epi- 
glottis, hold the tube exactly in the median line, and bear in mind 
the difficulties it must overcome in order to reach the larynx. 

The most common accident during- intubation is the introduc- 
tion of the tube into the esophagus. Cases also have been reported 




Fig. 296. — Extubation. First step. Gag in position. Extractor is 
guided along the left index finger until the beak enters the lumen of the 
tube. Original. (Fischer.) 



wherein the membrane was pushed downward by the tube without 
relief of the stenosis, requiring a reintroduction. 

The American Pediatric Society's collective investigations 
show a mortality of 21 per cent, in laryngeal diphtheria or croup, 
and 27:24 per cent, in intubated cases combined with antitoxin. 

Intubation in Chronic Stenosis. — It is proper here to mention 
the uses of intubation for chronic stenosis and for laryngeal papillo- 
mata. O'Dwyer mentions the use of intubation in chronic stenosis : 
1, for cicatricial stenosis due to injury from syphilis and trauma- 
tism; 2, narrowing of the space both below and above the vocal 
bands from the products of inflammation — simple, tuberculous, 
specific, malignant, hypertrophic, and pachydermia laryngis ; 3, for 



464 



INFLUENCE OF GENERAL DISEASES. 



the cure of granulations resulting from long-continued wearing of a 
tracheal cannula ; 4, in papillomata of the larynx ; 5, deformities of 
the larynx from injury or disease; 6, ankylosis of the cricoarytenoid 
articulation, and arthritis deformans of the same part] 7, aphonia 
spastica. 

After the introduction of the tube the child should be returned 
to bed and the steam inhalations continued. As the membrane 
separates and the swelling of the mucosa subsides, the tube is prone 
to loosen and become expelled during coughing. Should the tube 




. 297. — Extubation. Second step. The beak of the extractor holding the 
tube firmly; the operator withdraws the tube. Original. (Fischer.) 



slip downward into the trachea an immediate tracheotomy becomes 
necessary, through which the tube is easily removed. 

Feeding after Intubation. — Several plans have been devised by 
clinical observers for feeding children who have been intubated 
on account of the discomfort arising from the liability of liquids 
to enter the trachea. Whenever possible mouth feeding is prefer- 
able, and semisolid food like custard, junket, milk toast, cornstarch, 
rice pudding, soft-boiled eggs, concentrated broths, jellies, water 
ices and ice-cream may be administered. Gavage and rectal feeding 
are extremely distasteful to most patients. The Casselberry method 
(Fig. 295) is usually employed. 



DIPHTHERIA. 465 

Extubation. — About six days after the onset of the laryngeal 
obstruction, providing respiration has been free during the preced- 
ing two days, it is generally safe to remove the tube. Never, how- 
ever, without watching the patient for at least an hour after extu- 
bating, inasmuch as the laryngeal mucosa sometimes swells suffi- 
ciently to demand reintubation. A case occurred in the Willard 
Parker Hospital where a tube was reintroduced forty times during 
the course of the disease. 

To extubate, the patient is prepared precisely as for intubation. 
The left finger is introduced until it comes in contact with the 
tube. The extubator, held in the right hand, is guided along the 
finger until its beak enters the lumen of the tube (Fig. 296). Firm 
pressure is then made on the lever of the extubator, with the right 
thumb and the tube lifted upward about one inch and then care- 
fully withdrawn from the throat (Fig. 297). 




Fig. 298. — A tracheotomy tube. 

Tracheotomy. — Whenever the obstruction to the respiration is 
below the larynx or above the level of the cords, or becomes so 
great within the larynx itself that the tube cannot be introduced, 
tracheotomy furnishes the only means of relief. Cases of this type 
are invariably severe and many fatalities from bronchopneumonia 
or toxemia are recorded. 

The indications having been heretofore defined, the operation 
is performed as follows: Jackson advocates the Schleich infiltra- 
tion anesthesia with the patient in the Trendelenburg position, 
which position should be maintained for twenty-four hours subse- 
quent to the operation. 

The high tracheotomy operation is preferable to the trache- 
otomie inferieur of Trousseau, the hemorrhage in the former 
being much less. In performing high tracheotomy the usual 
aseptic precautions should be maintained in all particulars. After 
locating the cricoid cartilage with the lingers of the left hand the 
entire larynx is held firmly while the skin and subcutaneous tissues 
are incised in the median line down to the outer surface of the 
trachea. If time permits all bleeding points should now be ligatured 
before opening tlie trachea. Whenever suffocation is imminent the 
hemorrhage may be partially controlled by the pressure of re- 
tractors. 

30 



466 



INFLUENCE OF GENERAL DISEASES. 



Incision is now made through the two or three upper rings of 
the trachea. The aperture is held open, either hy means of the 
dilator or by the introduction of a heavy probe or elevator, and the 
cannula (Fig. 298) slipped into position. Proper introduction of 
the cannula immediately causes a characteristic reflex cough, 
which forces quantities of blood and other secretions through the 
tube, and suffocation is at once relieved (Fig. 299). The cannula 
is now carefully secured by tapes tied around the patient's neck. 

There are certain difficulties which attend the operation of 
tracheotomy, the chief of which are hemorrhage, a too small inci- 
sion, asphyxiation either from obstruction to the cannula or dis- 




Fig. 299. — Lateral view of the tracheotomy tube in position. 



lodged membrane, and numerous complications in the form of infec- 
tion of the tracheal wound, septic pneumonia, ulcerations of the 
trachea, and erysipelas are sometimes observed. Incidentally, the 
tracheotomy tubes commonly sold are too short for adults; there- 
fore, the surgeon should keep the larger sizes and shapes on hand. 
After-treatment. — The surfaces around the tracheal wound 
should be lightly pac!:cd with sterile gauze, the patient placed in. 
bed with the he^d lowered, and one cr two layers of thin gauze 
placed over the opening cf the tube. The inner cannula should be 
removed every two cr three hours and thoroughly cleansed in car- 
bolic solution. Steam inhalations are soothing and tend to prevent 
bronchial complications. Whenever performed for diphtheria under 
antitoxin treatment, it is not usually necessary to wear the tube 
longer than from three to five days, after which it may be removed 
and the wound allowed to heal. 



SCARLATINA. 467 



Sequelae as Affecting the Ear, Nose and Throat. 

Paralysis of the Soft Palate. — The occurrence of faucial paral- 
ysis before the separation of the diphtheritic membrane, due to 
involvement of the deeper tissues, renders the prognosis unfavor- 
able. Postdiphtheritic paralysis is self-limited, but is prone to 
extend over a large portion of the muscular system. Whenever 
the soft palate is the seat of paralysis, the patient swallows with 
difficulty and fluids tend to regurgitate through the nose. There is 
also a peculiar nasal character to the voice. It is sometimes neces- 
sary to feed by gavage for a short time. The duration of postdiph- 
theritic paralysis ranges from three weeks to six months, after 
which it gradually disappears. Chronic rhinitis and diseased ade- 
noids and tonsils are among the sequelae of diphtheria. 



SCARLATINA. 

I. THE EAR. 

Acute purulent otitis media is the most common complication 
of scarlatina. * The younger the child the greater the frequency of 
otitic involvement. This is probably due to the anatomical forma- 
tion of the Eustachian tube in young children. It occurs more fre- 
quently when the mucosa of the nose and throat is severely 
involved, and the infection extends through the Eustachian tube 
from the pharynx. Generally, both ears are affected. About 12 
per cent, of all cases of chronic purulent otitis media are the result 
of scarlet ,fever. In 185 cases of scarlatinal acute purulent otitis 
media Bezold found: — 

In 30 entire destruction cf the membrana tympani, with the loss of 
one or more ossicles. 

In 59 the perforations comprised two-thirds or more of the membrane. 

In 13 there were small perforations. 

In 44 there were granulations or polypi. 

In 15 there was total loss of hearing on one side. 

In 6 there was total loss of hearing on both sides. 

In 77 the hearing distance for low voice was less than 20 inches. 

Mastoiditis is not common in simple scarlatina, but is compara- 
tively frequent whenever the scarlatinal infection is mixed with 
diphtheria, measles, or other infections. Duel in his report of 6000 
cases found mastoiditis in two cases of uncomplicated scarlatina, 
20 in combined scarlet fever and diphtheria, and 2 in combined 
scarlatina, diphtheria, and measles. 

MacCullum in a study of 5000 cases of scarlet fever found 
mastoiditis in % 00 of 1 per cent. The author believes it to occur 
more frequently, that if is often unobserved, and that a timely 
mastoid operation would lower the percentage of chronic purulent 
cases and conserve the hearing function. MacCullum further found 
thai a combination of two exanthemata produced middle-ear sup- 
puration in 50 per cent., with a marked tendency to be bilateral und 



468 INFLUENCE OF GENERAL DISEASES. 

to extend to the mastoid. Scarlatina causes more cases of deafness 
and deaf-mutism than any other disease of childhood, 10 per cent., 
according to May, being- due to this cause. The occurrence of 
middle-ear inflammation in scarlatina has been reported as 
follows : — 

Downie 12.6 % 

Finlayson 10 " out of 4339 cases. 

Caiger 11 " " " 4015 " 

MacCullum 18 " " " 5000 " 

Duel 20 " " " 6000 " 

Burckhart 33 " of his cases. 

Fischer 20 " out of 397 " 

Purulent otitis media may occur as early as the fourth day of 
the disease or as late as the fortieth. 

Symptoms. — The symptoms are similar to those observed in 
purulent otitis from other causes (Chapter XVIII). In all cases 
of scarlet fever the ears should be carefully inspected daily. Pain 
in the ear, rise of temperature, and inflammation and bulging- of the 
drum membrane serve to establish a diagnosis. Purulent otitis 
media is more likely to develop at the height of the nasopharyngeal 
process. There is great destruction of the drum membrane, due to 
coagulation necrosis caused by the toxins. Suppuration is prone 
to be protracted unless an early incision of the drum membrane i.5 
made and persistent local treatment maintained. Residual perfora- 
tions nearly always remain. If the otorrhea becomes chronic the 
process is characterized by odor, deafness, and the development of 
polypi, granulations and bone necrosis. Deafness during the attack 
is considerable, but this improves as the inflammation subsides. 
Otitis interna from panotitis, or involvement of the auditory nerve 
or cochlea, may occur. 

Prognosis. — In simple scarlatinal otitis, when skillfully treated, 
the prognosis is favorable. When the infection is mixed and the 
disease is unduly septic, or when it occurs in weakened children 
who have adenoids, the otorrhea is liable to become chronic, the 
hearing impaired or lost, and mastoid, labyrinthine, and cerebral 
complications may occur. Prompt and vigorous treatment (Chapter 
XVIII) favorably affects the prognosis. 

II. THE NOSE. 

The nasal manifestations of scarlatina are chiefly a slight 
rhinitis with coryza, and, occasionally, epistaxis. In severe types 
there is extensive ulceration of the turbinals and septum, and 
involvement of the accessory sinuses. Adhesions between the 
turbinals and septum may result from the ulcerative process. 

III. THE OROPHARYNX. 

During the first twenty-four hours the mucous membrane 
shows a fine vivid red erythema, which consists of minute red points 
on the hard palate, except in the mildest cases. The tonsils are 



MEASLES. 469 

sometimes covered with a tenacious grayish membrane, of strepto- 
coccic origin (unless the case be one of double infection with diph- 
theria). In moderate cases the tonsils are inflamed as in follicular 
tonsillitis, the membrane being easily detached from the crypts. 
The diphtheritic form generally occurs later in the disease, after 
the fever has disappeared. In very severe forms this membrane 
may extend over the entire fauces and into the nose, middle ear, 
larynx, etc. The color varies from grayish, or greenish, to black 
(gangrenous). To differentiate this form from diphtheria requires 
the art of bacteriology. Gangrenous angina may be present from 
the start, or be preceded by a grayish membrane which sloughs. 
Cervical adenitis is common. 

IV. THE LARYNX. 

Acute laryngitis may accompany any attack of scarlatina, and 
edema of the larynx, in the extremely congestive type, sometimes 
occurs. 

TREATMENT OF THE EAR, NOSE AND THROAT. 

In all cases of scarlatina wherein the nose and nasopharynx 
become filled with secretions they should be irrigated with hot 
normal salt solution as in diphtheria (Fig. 290), the frequency being 
governed by the severity of the process. Vigorous blowing of the 
nose should be avoided, inasmuch as the act is liable to force infec- 
tion into the Eustachian tube. At the onset of an attack of purulent 
otitis media the drum membrane should be incised (Fig. 54), and the 
ear otherwise treated in the manner described in Chapter XVIII. 
The occurrence of mastoiditis of scarlatinal origin calls for an early 
mastoid operation. 

MEASLES. 

Ear Complications. — The aural complications of measles are 
chiefly confined to the purulent and catarrhal forms of otitis media. 

The Eustachian tube is the usual pathway of infection, but 
Richardson and others have demonstrated that the infection may 
reach the tympanum through the blood-vessels and lymphatics. 

The tympanic cavity probably contains either a serous or puru- 
lent exudate in from 70 to 90 per cent, of cases of measles. Weiss 
found the membrana tympani inflamed in 50 per cent, of all children 
affected with measles. 

An attack of acute purulent otitis media, when complicating 
measles, usually starts soon after the beginning of the disease, and 
only rarely is a late manifestation. 

Tobeitz contends thai in measles Ave are dealing with a primary 
exanthematous affection of the middle ear. That ear complications 
are common is proven by statistical reports. Out of 501 cases of 
measles observed by Downie in the Children's Hospital, Glasgow, 
otitis media purulcnta acuta occurred in 26.1 per cent. In 1000 
cases of measles MacCullum found 24 per cent, of otitis media 



470 INFLUENCE OF GENERAL DISEASES. 

purulenta acuta. Mastoiditis is more common in measles than in 
scarlatina, is prone to be quick in developing and severe in type. 
The invasion is usually so rapid and the symptoms so profound 
that it becomes imperative to perform the mastoid operation with- 
out delay. Moreover, it is justifiable to operate early on account 
of the severity of the infection. Bilateral middle-ear infection and 
bilateral mastoiditis are extremely common in measles. 

Tobeitz found middle-ear complications in 86 per cent, of all 
fatal cases of measles, and Bezold found ear disease in 17 out of 18 
fatal cases of measles. 

Nose Complications. — Acute coryza is characteristic of the 
initial stage of measles, and the discharge is at first mucoid, later 
mucopurulent or purulent. Sometimes there is epistaxis. The 
inflammatory engorgement of the nasal mucosa produces great 
discomfort to the patient, and nasal respiration is proportionately 
obstructed. Headache is common and the accessory sinuses some- 
times become involved sufficiently to induce severe pain and a 
sensation of pressure. Ulceration and adhesions result in the 
severer cases. The inflammatory process is prone to extend to the 
Eustachian tube, where it causes obstruction and consequent rare- 
faction in the tympanum, which in turn induces tympanic effusion; 
or infection enters the tympanum, where it induces purulent otitis 
media. 

Mouth and Pharynx Complications. — "Small, irregular, rose- 
colored spots with a very minute bluish speck just large enough to 
be visible in the centre, of the rose area," as described by Koplik, 
are seen upon the mucous membrane inside the cheek during the 
first day of the attack in over SO per cent, of cases. 

The pharyngeal mucosa is inflamed. Blotchy areas of con- 
gestion similar to the eruption on the skin, some of which are even 
purpuric, develop upon the palate. 

Follicular tonsillitis is common, but streptococcic membrane 
formation rarely occurs. The lymphoid tissue in the vault of the 
pharynx and the faucial tonsils becomes swollen from the irrita- 
tion of the nasal discharge. 

Postmortems on cases of measles show inflammation and 
infiltration of adenoid tissue in the nasopharynx and pharynx. 

Laryngeal Complications. — Simple acute laryngitis is usually 
present at the outset of the disease. The voice is hoarse and a dry 
cough persists. The process may be so severe as to produce edema 
and ulcerations. Bronchitis is almost invariably present, and 
pneumonia is an occasional complication. 

Local Treatment. — The preventive treatment of car compli- 
cations is conducted by the employment of soothing and cleansing 
local medication to the mucosa of the nose and throat during the 
stage of . coryza. A spray of alkaline solution or of normal salt 
solution, to either of which sufficient adrenalin may be added to 
make the solution 1 : 10,000, used every two hours serves to wash 
away retained secretions and to reduce the swelling in the nose 
and about the Eustachian tube. In this manner tubal obstruction 



MEASLES. 471 

and its consequences may be avoided. Even when a slight collec- 
tion of serous or seromucous fluid has collected in the middle ear 
no operative interference is necessary so long as no bulging of the 
membrana tympani occurs, and the treatment must be directed to 
the Eustachian tube by inflation after thorough cleansing of the 
nose and nasopharynx. In purulent cases with severe pain and 
bulging of the drumhead early paracentesis and local treatment the 
same as for otitis media purulenta acuta should be followed. 

Rubeola (Rubella ; German Measles) ; Rotheln. — Corlett de- 
scribes rubeola or rubella as "a mild form of infection which always 
follows a benignant course and first appears as a general or consti- 
tutional disease, accompanied by a slight run of temperature and 
slight feeling of illness." 

It is an affection characterized by a pinkish rash which appears 
first upon the face and scalp and gradually extends downward over 
the entire body, moderate rise of temperature and desquamation. 
Moderate coryza and suffusion of the eyes generally precede the 
appearance of the eruption, and sneezing may or may not be 
present. The throat symptoms consist in moderate swelling of the 
pharynx and tonsils and slight cough. No eruption appears upon 
the buccal mucous membranes. According to Thierfelder, swelling 
of the subauricular and superior jugular lymphatic glands is a 
constant prodromal symptom, and Atkinson states that enlarge- 
ment of the superficial lymphatic glands of the neck may be the 
most striking symptom. The disease runs a mild course, the 
prognosis is good, and no specific treatment is necessary. The 
patient should remain in bed until the fever and eruption subside ; 
the diet should be light and mild cathartics administered. 



CHAPTER XXXII. 

THE INFLUENCE OF GEXERAL DISEASES UPON THE 

EAR, NOSE AXD THROAT. 

{Continued.) 



TYPHOID FEVER. 

The principal typhoid lesions found in the upper respiratory 
tract are active hyperemia with slight erosions of the mucous 
membrane, which sometimes permit the entrance of other organ- 
isms, deep ulcers, perichondritis, ulceration of the adenoid tissue 
similar to that of Peyer's patches, and middle-ear inflammation. 

Ear.— The mechanical (catarrhal) type is the most common 
aural complication of typhoid fever, but acute purulent otitis media 
occurs in from 2 to 3 per cent, of cases. In 579 cases of typhoid 
fever observed by McCaw acute purulent otitis media occurred in 
29. Four of this number developed mastoiditis, with two deaths. 
Day reports one fatal case of typhoid mastoiditis in which infection 
was due to embolism. 

There is a greater destruction of the membrana tympani than 
in ordinary purulent otitis, and the perforations are often double 
or multiple (Figs. 174 and 175). Mastoiditis is rare, but invariably 
severe in this type, with a large percentage of fatalities, as shown 
by reports of Day and McCaw. 

Hemorrhage into the labyrinth is a rare complication, but 
occurs as often in typhoid as in any other infectious disease. 

Nose. — Epistaxis is an early and common symptom of typhoid 
fever. It is observed in about 20 per cent, of typhoid cases. Dur- 
ing the later stages crusts are prone to form upon the nasal mucosa, 
which are picked by the semiconscious patient until ulcers are 
produced. The septal cartilage may thus become perforated. 

Mouth and Pharynx. — In severe or neglected cases of typhoid 
fever the tongue becomes dry, glazed or fissured and the lips ulcer- 
ated from continued picking by the patient. Clean-cut superficial 
ulcers on the soft palate and pharynx are occasional complications. 

Anders mentions patchy whitish elevations on the tonsils, 
which ulcerate. 

Larynx. — Superficial laryngeal inflammation is present in a 
large proportion of typhoid cases. There is a tendency to deep 
ulceration in typhoid laryngitis, due to metastatic thrombosis or to 
ordinary pus bacteria. The trachea is occasionally the seat of 
ulceration. 

In an exhaustive study of 360 cases of typhoid by Jackson 1 
the following laryngeal complications were found : — 



1 Transactions of the American Laryngological, Rhinological, and Otological 
Society, 1905, p. 223. 

(472) 



TYPHUS FEVER. 473 

Number examined 360 Cases. 

Ulcerative laryngitis in 68 " ( 18.9% ) 

Started as abscess of larynx in 4 " ( 5.9%) 

Required tracheotomy 8 " (11.8%) 

Perichondritis with necrosis in 6 " ( 8.8%) 

Perichondritis without necrosis in 11 " (16.2%) 

Abscess from perforation in 2 " ( 3.0%) 

Ulcerative tracheitis, in 9 " (13.2%) 

Ulcerative tracheitis with perforation and emphysema in . . . 1 Case. ( 1.5%) 

Ulcerative tracheitis with abscess of the thyroid glands 1 ( 1.5%) 

Pus foci in remote locations in 15 Cases. (22.0%) 

Associated with acute purulent otitis media 11 (16.2%) 

Associated with leukophlegmasia 6 " ( 8.8%) 

Died 4 " (5.9%) 

These ulcerations were located as follows : — 

Epiglottis 42 Anterior commissure 4 

Aryepiglottidean 22 Infraglottic region 3 

Interarytenoid space 18 Trachea _ 4 

Arytenoids 10 Bifurcation 2 

Ventricular bands 7 Bronchi 2 

Ventricle 5 Vocal bands 1 

Typhoid laryngeal ulceration is rarely observed prior to the twenty- 
first day of the disease. In postmortems on typhoid patients in 61 cases 
there were 14 with ulceration in the, larynx (St. Bartholomew's Hos- 
pital report) ; in 113 autopsies, 20 with ulceration and perichondritis 
(Vincent) ; in 6513 cases, 439 deaths, ulcer in 30 per cent. (Onskow) ; 
in 20C0 autopsies, 107 ulcerative laryngitis cases ( Munich) . 

General Remarks on Treatment. — From the commencement of 
the disease the nose, mouth, and oropharynx should be cleansed at fre- 
quent intervals ; the fountain syringe filled with hot normal salt solu- 
tion, as recommended in diphtheria (Fig. 290), is a convenient method. 
The teeth should be brushed twice daily with a good dental powder, and 
the gums and tongue swabbed with a J /z per cent, solution of carbolic 
acid or a saturated solution of boric acid. The nose, throat, and larynx 
may also be sprayed with a 2 per cent, solution of camphor and menthol 
in benzoinol. Intratracheal injections of the same formula bring great 
relief. Medicated steam inhalations are soothing to the mucous mem- 
brane. 

Mild laryngeal edema may be controlled by sprays or intratracheal 
injections of adrenalin solution 1 : 5000. Symptoms of stenosis require 
tacheotomy or intubation, the latter being without efficacy in laryngeal 
edema and adductor paralysis. Early tracheotomy (see page 465), per- 
formed under local anesthesia (Schleich's solution), is advisable as soon 
as respiration becomes seriously impeded. The remarkable success 
attending the use of vaccine for the prevention of typhoid fever is 
worthy of note in relation to its value as an eliminator of the above- 
described serious complications. 

TYPHUS FEVER. 

At the time of an attack of typhus fever the dorsum of the tongue 
becomes In-own and fissured. In severe cases gangrene of the nose, can- 
crum oris, and abscess of the parotid gland may develop. Noma of the 
auricle is a rare complication and originates in the cartilaginous meatus. 



474 INFLUENCE OF GENERAL DISEASES. 

PERTUSSIS (WHOOPING-COUGH.) 

During" the course of pertussis ulcerations sometimes develop upon 
the under surface of the tongue as a result of trauma. During the 
early stages of the disease some rhinitis is present. Epistaxis may 
appear as a complication, and is induced by the train of the paroxysms 
of coughing upon the hyperdilated anterior septal vessels. Patients in 
advanced life who suffer from pertussis sometimes develop labyrin- 
thine hypertrophy, congestion or hemorrhage. Submucous hemor- 
rhage in the palate, tonsils, or pharynx, granular pharyngitis, and con- 
gestion and hemorrhage of the larynx are among the complications of 
the disease. According to Gottstein, edema of the larynx is quite 
common. 

EPIDEMIC PAROTITIS (MUMPS). 

During the active stage of an attack of epidemic parotitis, espe- 
cially when bilateral, patients experience considerable difficulty in 
opening the mouth for speech or deglutition. The orifices of Stenson's 
ducts opposite the second upper molar teeth may show come, conges- 
tion, with increased or decreased flow of saliva. Rarely the parotid 
gland suppurates or becomes gangrenous. There may be otalgia, or 
very rarely otitis interna, with deafness, the anatomical explanation 
of this being still problematical. Rarely an otitis media purulenta 
acuta develops during convalescence. Labyrinthine hemorrhage is a 
rare complication. (Toynbee.) Urbantschitsch (1906) reports a case 
in a twelve-year-old deaf-mute. It is usually accompanied by tinnitus, 
vertigo, nausea, and frontal or occipital pain. The following typical 
case is reported from the author's case book: — 

Cask IV. F. W., male, aged eighteen years, consulted me on April 2, 1912, 
with the following history: On January 2, 1912, he had suffered from an attack 
of mumps of extreme severity. During the early stage he had fainting spells 
and his family physician had told his mother that the pancreas was evidently 
involved. Two weeks from the onset of the attack he hecame extremely dizzy 
and complained of excessive tinnitus in the right ear. Three days later he be- 
came completely deaf in the right ear, and his family physician stated that the 
eyes were slightly fixed toward the right side. For four days during this time 
he was almost entirely unconscious; the vertigo remained severe, and continued 
for over two weeks. During the four severest days forced feeding became 
necessary. There was no abscess. He gradually improved and the vertigo finally 
disappeared, but his hearing remained nil. A sister contracted the disease from 
him and her attack was followed by >a double ovaritis, and for a period of one 
week she had double vision. 

At the time of my examination the patient had entirely lost the hearing of 
his right ear, both air and bone conduction being destroyed, as proved by the 
employment of the noise producer. The semicircular canals had evidently some- 
what improved, but the nystagmus upon irritation of the right side lasted less 
than two-thirds of that upon the left side. He was examined on January 4, 1913. 
He is still completely deaf to all sound in his right ear, but the vestibule upon 
the affected side is now irritable. 

SMALL-POX. 

Briefly stated, the ear, nose, and throat complications of small-pox 
are inflammation, swelling, edema, and hemorrhage of the mucous 
membranes, edema of the glottis, ulceration of the larynx, and puru- 
lent otitis media. They are not constant, and the ordinary methods of 
treatment for similar conditions may be adopted. 



INFLUENZA. • 475 

INFLUENZA. 

Influenza usually attacks the entire upper respiratory tract, often 
extending to the middle ear. The invasion is bacterial and is character- 
ized by pain, rise in temperature, depression, and exhaustion. 

Ear. — In some epidemics the disease manifests a strong predilec- 
tion to attack the middle ear by extension from the nasopharynx 
through the Eustachian tube. It is extremely violent and rapid in its 
course ; mastoiditis and serious intranasal involvement are common. 
Kerley reports (1905) that 58 out of 77 cases of otitis media purulenta 
acuta in children were caused by influenza, The exudate from the 
perforated drumhead during the early stages is usually hemorrhagic 
and fibrinous in character, after which it becomes entirely purulent. 

Pain. — Pain is severe and often persists several days after the 
perforation of the drumhead. The invasion of the middle ear is usu- 
ally streptococcic; hence the severity of the symptoms and the large 
proportion of mastoid and other complications. In severe types there 
is rapid destruction of both soft tissue and bone. 

Cheatle has observed that, when influenza mastoiditis occurs in 
individuals who have but slight development of mastoid cells, and mas- 
toid antra which are surrounded with dense impervious walls, there is 
grave danger of the infection forcing its day through the thin poste- 
rior antral wall to the posterior cranial fossa, or through the thin roof 
(tegmen antra) to the middle cranial fossa, thus producing meningitis, 
brain abscess or sinus-thrombosis. Influenza occurring in those who 
have chronic purulent otitis media produces fresh infection with all the 
symptoms of the acute attack. 

Treatment. — For the general treatment of influenza the reader 
is referred to works on general medicine. 

On account of the virulency and rapidity of the purulent process 
when occurring in the middle ear, it becomes imperative that an in- 
cision of the drum membrane be made as soon as the diagnosis is 
established, and further treatment carried out exactly as described for 
purulent otitis media (Chapter XYITI). 

Nose. — Acute rhinitis due to influenza is fullv described in Chap- 
ter XXXIII. 

Mouth and Throat. — Acute pharyngitis and simple acute and 
lacunar tonsillitis are commonly associated with influenza. The 
mucous membranes become intensely congested and the lymphoid tis- 
sue markedly swollen. Cultures from the tonsil contain mixed influenza 
bacilli, streptococci, etc. The cervical lymph glands are usually much 
swollen, and when they suppurate the secretion invariably contains 
streptococci. It is possible that those which do not suppurate contain 
Duly the influenza bacillus or other pus bacteria, not streptococci. 

Larynx.— Various grades of laryngitis accompany the upper 
respiratory type of influenza. Hemorrhagic laryngitis is frequently 
observed, and in rare instances edema and ulcerative processes occur. 

Various sequelae result from influenza, and they are due to peri- 
pheral neuritis. Anosmia and parosmia are common. Paralysis of the 
soft palate, paralysis of the vocal cords, abductor paralysis, both 
unilateral and bilateral, may occur early during convalescence. 



476 INFLUENCE OF GENERAL DISEASES. 



EPIDEMIC CEREBROSPINAL MENINGITIS. 

In cerebrospinal meningitis coryza is usually present, and 
according to Finkelstein the meningococcus is always present in 
the nasal discharges. 

Ear. — The ear is occasionally the seat of a complicating otitis 
media purulenta, but the chief lesion is labyrinthine effusion 
(Chapter XXVIII), which usually results in permanent deafness 
and mutism. 

LOBAR PNEUMONIA. 

In young children acute purulent otitis media may complicate 
lobar pneumonia, especially when the nasopharynx is inflamed. 
Craiger reports 125 cases of otitis media purulenta acuta out of 
1000 cases of lobar pneumonia. 

ERYSIPELAS. 

Erysipelas of the upper respiratory tract occurs as a direct 
inoculation, and is usually an autoinfection from the nasal mucosa. 
The mucous membranes of the mouth and throat become swollen 
and the process extends into the larynx. Generally laryngeal 
edema, when it occurs in erysipelas, is caused from without the 
larynx and not from within. 

Ear. — Erysipelas of the auricle usually follows traumatism. 
Primary erysipelas of the auricle is rare, being generally an exten- 
sion from the face or from a mastoid incision. Erysipelas of the 
ear is more fully described in Chapter X. 

Nose. — Erysipelas of the nasal mucosa is usually secondary to 
that of the contiguous skin. It is prone to become bilateral and to 
cause complete nasal obstruction. The appearance of the mucosa 
is dusky red, with many ecchymotic areas. 

The cervical lymphatic glands become enlarged, with a marked 
tendency to suppurate. The accessory nasal sinuses are almost 
invariably involved. 

Fatal meningitis may result by direct extension through the 
cribriform plate of the ethmoid. 

Pharynx. — Pharyngeal erysipelas commences with a disagree- 
able sensation of smarting in the throat, followed by swelling and 
dysphagia. The throat is vividly red, dry, glistening, and swollen. 
Blebs occur on the mucosa over the cheek, tonsils, and pharynx, and 
the uvula is markedly edematous. In some cases there is a fibrinous 
exudate over the tonsils and phlegmonous ulceration is a rare 
complication. It is apt to spread to the nose. Eustachian tubes, 
tympanum, and mastoid cells, producing violent inflammation in its 
path. The cervical glands are more involved than in the pure nasal 
type. 

The prognosis is very grave. 

Treatment. — In addition to the more general measures else- 
where described, local cleansing measures are indicated for the 



MALARIA. 477 

relief of distressing symptoms and the removal of secretion. The 
oropharynx should be douched with hot normal salt solution at 
intervals of from two to six hours (Fig. 290). 

Larynx. — Erysipelas seldom involves the larynx and only 
secondarily to that of the skin of the face and oropharynx. 

The appearance of the laryngeal mucosa is similar to that 
described in the pharynx. Great dyspnea, dysphagia, and aphonia 
appear, early necessitating tracheotomy, with the result that the 
tracheal wound generally becomes infected with the disease. The 
prognosis is extremely grave. 

Treatment. — Early tracheotomy and strong stimulating 
general treatment to tide over the crisis is necessary. 



RHEUMATIC FEVER. 

Acute articular rheumatism is probably due to a diplococcus — 
the Diplococcus rhcumaticiis (Fritz Meyer). This diplococcus has 
been frequently found on the tonsils, and in the subcutaneous 
nodules which are more common in England and America. It is 
possible that this agent may enter through an inflamed mucous 
membrane. Triboulet and Coyon in two cases found a diplococcus 
or diplobacillus which produces in rabbits violent endocarditis, with 
large masses of vegetations about the mitral valves. Sixty per cent, 
of all cases of tonsillitis, when accompanied by fever, are said to be 
of rheumatic character. Packer, Meyer, Wade and Gurich have 
reported cases wherein endocarditis and acute articular rheumatism 
followed lacunar tonsillitis. 

In an attack of rheumatic fever the laryngeal joints may 
become involved, producing fixation and varying degrees of anky- 
losis. 

Mosely has collected 11 cases of cricoarytenoid ankylosis occur- 
ring in the rheumatic. 

Ear. — Rheumatic individuals sometimes suffer from otalgia, 
Which is out of proportion to the local pathological appearances and 
it is claimed to result from interossicular inflammation. Rheumatic 
paralysis of the auditory nerve has been reported as occurring in a 
few cases at the time of the general attack. 

Treatment. — For the general treatment of rheumatism the 
reader is referred to text-books on general medicine. The local 
treatment of acute tonsillitis is described in Chapter XLV. 



MALARIA. 

Acute rhinitis of an obstinate nature is sometimes the pro- 
dromal symptom of malaria. Hemorrhage from the nose and 
pharynx, rarely from the larynx, may occur in severe attacks. 
Neuroses of the palate and pharynx, producing dysphagia, and of 
the larynx, causing hoarseness or spasmodic coughing, have been 
reported. 



478 INFLUENCE <>l ; GENERAL DISEASES. 

Ear. — Malaria sometimes produces disturbances of hearing 
through its effect on the auditory nerve in its course or termi- 
nations. 

Quinine given for the disease is liable to affect the internal 
ear, especially if there is already some disease of this organ, brought 
about by selective congestion of the ear through vasomotor 
influence (Kirchrier). 

HYDROPHOBIA. 

Aural Symptoms. — Hyperesthesia of the ears is common in the 
prodromal stage of hydrophobia. 

Laryngeal Symptoms. — In the beginning there is congestion, 
and the voice may be husky. Dysphagia occurs earl}-. During the 
stage of excitement a noise, a draught of air, or verbal suggestion 
may produce spasm of the mouth and larynx, with a sense of 
dyspnea. Effort to eat causes intensely, painful spasm ol the 
muscles of the larynx and the elevators of the hyoid bone. This 
produces the so-called fear of water. No relief is obtained from 
treatment. 

RHINOSCLEROMA. 

In accordance with the more recent investigations rhino- 
scleroma is believed to be of bacterial origin, the Frisch bacilli 
within the Mikulicz cells and in the surrounding tissues having 
been found in all of the cases. This disease is characterized by the 
formation of nodular granulomata in the vestibule of the nose. The 
nodules are of extreme hardness, and occur either singly or in 
groups. They are of slow growth, gradually extending outward 
upon the lip and cheek and inward by invading first the septal and 
inferior turbinal tissues, thence into the rhinopharynx, and finally 
involving the Eustachian tube, pharynx, larynx, trachea, and bronchi. 

The disease is chiefly prevalent among the inhabitants of 
Russia, Austria, Eastern Prussia, and Central America, where it is 
endemic. It is about equally divided between the sexes, and 
according to Gottheil all cases occur in the third decennium or 
later. Guntzer controverts this and contends that the disease, 
though mostly found in adults, may begin during childhood, and 
cites cases affected in childhood and infancy. It is confined chiefly 
to the pi )' >rer classes. 

Diagnosis. — The diagnosis, according to Gerber, is based upon 
eight observations, which are as follows : — 

"1. Changes of the nose externally which would cause suspi- 
cion are wanting in most cases. 

"2. The occlusion of the nose, which is often the beginning of 
the disease, shows on rhinoscopic examination to be due to the 
thick, rigid, at the beginning soft, later very hard, more or less 
nodular swellings of the mucous membrane of both the septum and 
turbinates and which sooner or later fill up the entire nose. 

"3. These typical changes are not always found anteriorly but 
are seen first, with posterior rhinoscopy, as a narrowing of the 



GLANDERS. 479 

choanse from thickening of the septum, the Eustachian prominences 
and the lateral folds of the mucous membrane. 

"4. Often the pharynx is found normal on direct examination, 
but here too in some cases we see scleromal infiltration, which 
reminds one of syphilis and tuberculosis, hypertrophies, contrac- 
tions, and tumefactions of the soft palate and the posterior pharyn- 
geal wall. 

"5. Sooner or later, mostly in the very chronic course of the 
disease, the larynx becomes affected by stenosis, due to subglottic 
swelling; the swelling may be above the chink. In some cases the 
larynx is primarily affected and the disease extends upward. 

"6. The secretions may be normal ; in other cases may show a 
picture of ozena and 'ozena trachealis.' 

"7. It is characteristic of these thickenings, excepting in the 
very beginning, that they are hard, tough and rigid, and do not 
ulcerate, although a superficial secondary erosion is seen now and 
then. 

"8. Finally, the microscopical examination will show the 
Mikulicz cells and the bacilli of Frisch." 

Dr. J. H. Giintzer, in an exhaustive thesis, 2 reports two cases 
treated at the Manhattan Eye and Ear Hospital by vaccine and 
radiotherapy, and concludes that : "The X-ray treatment, at this 
time, holds out the best prospects of a possible cure for scleroma; 
that the vaccine treatment has at least caused a local immunity and 
may be a means of possible cure if used for a long time, and, as to 
frequency and quantity, in proper dosage, and that, with no criteria 
to guide my original work in this disease, these points in the vaccine 
treatment still need to be worked out, and that surgery has only an 
elective place in the treatment of scleroma, and is useful only as an 
auxiliary." 

In both cases the vaccine treatment was given for a period of 
several months, after which it was combined with the X-ray treat- 
ment, given at intervals of two or three days. In both cases there 
was marked improvement in the general health, the infiltration 
materially subsided, and the symptoms ameliorated. 

GLANDERS. 

_ This is a rare disease which is peculiar to horses and due to the 
bacillus mallei. It is communicable to men through abrasions in 
the skin or mucosa, the infection being acquired from contact with 
infected horses. 

Pathology. — There are granulomatous tumors made up of 
epithelioid cells and the glanders bacillus. The nodules break 
down early, with the formal ion of ulcers. The mucous membrane 
of the nose becomes inflamed and a profuse purulent discharge 
persists. Small, firm nodules appear first 'on the septum and turbi- 
nals; these rapidly become first red, then yellow from necrosis. 



'-Scleroma of the Upper Respiratory Ti 



480 INFLUENCE OF GENERAL DISEASES. 

and in a few days they break down, leaving ulcers. The nose is 
usually greatly swollen. The same process may attack the lips, 
tongue, tonsil or pharynx. The maxillary and frontal sinuses may 
be involved, and rarely the ethmoidal or sphenoidal sinus. 

Prognosis. — The disease is usually fatal in from eight to ten 
days. 

Treatment. — Treatment is unavailing, but relief is obtained 
from ordinary cleansing measures. 

ACTINOMYCOSIS. 

Synonym. — Lumpy jaw. 

This is a chronic infectious disease due to the actiiwmyccs or 
ray-fungus, the Streptothrix actinomyces. It is rare in this country. 
The mode of infection is probably through the food. It is common 
in cattle, and they are supposed to acquire the affection from fungus- 
laden straw, chaff, and grain. The fungus gains entrance through 
abrasions in the mucous membranes. 

Pathology. — In the early stage there is a granuloma similar to 
that of tuberculosis, composed of round cells, epithelioid elements, 
and giant cells. Later there is a great increase in connective-tissue 
elements. Finally it breaks down and causes great destruction of 
the underlying structures. The tongue is sometimes involved. De 
Simoni reported a primary case in the nose, spreading to the palate. 
It has occurred in the antrum of Highmore. J. C. Beck reports a 
case involving the tonsils, the left tympanum and mastoid process, 
death occurring in one week from intracranial hemorrhage. Several 
cases involving the larynx have been reported by Heinrich and 
Henrici, in one of which it started in a carious tooth. 

Diagnosis. — The diagnosis depends upon the discovery of the 
ray-fungus in the pus. 

Symptoms. — A somewhat irregular nodule forms upon the lips, 
tongue or tonsil. The growth is rapid with but little pain; the 
nodule begins to break down in a few weeks, and, from numerous 
sinuses, pus and small yellow masses are discharged, which contain 
the streptothrix. 

Treatment. — The growth should be completely excised, and 
this is possible only when the disease involves the lips. On the 
tongue or tonsils the process is prone to extend to the digestive or 
respiratory tract. In recent cases the iodides in large doses may 
afford relief. 

LEPROSY. 

The contagion of leprosy is probably conveyed by the secretion 
of the nose, throat, and mouth. Sticker believes the initial lesion to 
be an ulcer on the nasal septum. The nose is more frequently 
involved than the larynx or pharynx. 

Pathology. — There is a formation of tubercles which consist of 
round-cell infiltration, of various sizes, with bacilli in large numbers 
about and in the cells. These gradually break down and extend, 
forming ulcers, and on healing form cicatrices. Involvement of the 



GOUT. 



481 



mucous membrane of the mouth, throat, and larynx is a later mani- 
festation of the disease. 

Symptoms. — There is diffuse infiltration of the septum and 
inferior turbinal, with congestion of the mucosa. Mucopurulent 
secretion is abundant, with a tendency to the formation of crusts. 
Small, yellow, shiny tubercles the size of a split pea appear upon 
the septum. The process is sometimes destructive to the cartilage 
and bones of the nose (Fig. 300). The faucial pillars and uvula are 
more often affected than the hard palate and tonsils. 

Likewise the epiglottis is more often affected than the laryn- 
geal structures. In severe cases the process extends throughout 




Fig. 300. — Leprosy. A native of Jamaica with marked nodular lesions 
of face, destruction of the nasal cartilages, and characteristic leonine 
expression. (Photograph loaned by Dr. E. Echeverria, of Costa Rica.) 



the larynx, causing hoarseness, dyspnea and perichrondritis, or 
necrosis of the cartilages. 

Prognosis. — Death often occurs from laryngeal complications 
or aspiration pneumonia. The tubercles ultimately ulcerate and 
usually heal. 

GOUT (PODAGRA). 

Acute pharyngitis or laryngitis of a very painful type may 
occur before or during an attack of gout. The mucosa appears 
intensely dry and glazed and the inula may be very edematous. 
Chronic catarrh of the mucous membrane of the nose and throat is 
common in the gouty. 

Pain is greater than the local condition seems to warrant, and 
it shoots up to the ears or to the temporomaxillary articulation. 

31 



432 INFLUENCE OF GENERAL DISEASES. 

Tophi have been found in the throat. 

The laryngeal symptoms of gout are similar to those of the 
nose and throat, and are characterized by swelling, congestion, and 
dryness. The edges of the true or false cords and the interarytenoid 
space are the parts commonly affected. The deposit of urates 
in the cords or in the cricoarytenoid joints is occasionally observed. 

Ears. — Eczema of the auricle or canal is common in gouty sub- 
jects. Tophi frequently occur on the auricle. Exostoses are some- 
times produced in the external auditory meatus, and some authors 
believe that otosclerosis may be due to gout. 

Treatment. — The treatment is necessarily dietetic and hygienic 
in accordance with the rules laid down in text-books on general 
medicine. 

DISEASES OF THE DIGESTIVE SYSTEM. 

The diseases peculiar to the digestive tract evince a marked 
tendency to become the exciting cause of inflammatory affections 
along the upper respiratory tract or to aggravate those already in 
progress and these local primary inflammations in the mouth or 
pharynx may extend by contiguity to the nose, ear, or larynx. 

(a) Teeth. — A general examination of the digestive tract 
should begin with the teeth. Foul, neglected, necrosed teeth favor 
the growth of deleterious micro-organisms, which are prone to 
induce secondary infection of the oropharynx. A suppurative 
process in and around the upper incisor teeth may burrow upward 
and form an abscess in the floor of the nose or in the septum. 
Necrosis of an upper bicuspid or molar tooth, by extending through 
the antral floor, becomes the exciting cause of empyema within the 
maxillary sinus. The severe pains sometimes associated with 
carious upper teeth tend to radiate to the ear. 

(b) Mouth. — Inflammations of the mucosa of the mouth, 
whether simple, aphthous, ulcerative, parasitic (thrush) or gan- 
grenous (noma), often extend to the neighboring mucous mem- 
branes. 

(c) Pharynx. — Ulceration or inflammation of the nasopharynx 
is a common cause of otalgia. In acute tonsillitis the pain is com- 
monly referred to the ear. These diseases are fully discussed in 
appropriate chapters. 

(d) Esophagus. — Esophageal diseases may extend to the 
larynx and pharynx. Malignant growths when located in the upper 
part of the esophagus eventually extend to the pharynx and larynx, 
producing paralysis, dysphagia, and aphonia. When the lower 
portion of the esophagus is the seat of cancer, pressure is brought 
to bear upon the laryngeal nerve, causing laryngeal paralysis, but 
the pain or paresthesia is referred to the tonsils or root of the 
tongue (Stein). 

(e) Stomach and Intestines. — Indigestion, whether due to 
gastric or gastrointestinal affections, is prone to evoke trouble- 
some congestion of the mucosa of the upper respiratory tract, which 



DISEASES OF DIGESTIVE SYSTEM. 483 

persists until the primary cause is eliminated. These disturbances 
vary from simple congestion to inflammation and hypertrophy. A 
characteristic symptom of this type is the patient's intolerance to 
examination of the fauces and pharynx, due to the hyperesthesia of 
these parts. 

In like manner digestive disturbances are believed to result 
from idiopathic affections of the nose and throat. The continuous 
swallowing of the discharge emanating from diseased adenoids and 
tonsils by children, or of pus from ozena, or suppurating accessory 
sinuses by adults, has a deleterious effect upon the digestive func- 
tions. Kerley calls attention to the prevalence of colds and adenoids 
in children who eat excessive amounts of cane-sugar. Stomatitis, 
aphtha, cancrum oris, herpes, nasopharyngitis and laryngitis are 
commonly of digestive origin. Cases of edema of the larynx due 
to catarrhal inflammation of the intestines and cirrhosis of the liver 
have been reported by Schrotter, Schmidt, and Lori. Hyperemia^ 
of the throat in the vomiting of gastritis or regurgitation of dyspep- 
sia is common. Butyric acid and other eructations from gastric 
fermentation irritate the mucosa of the upper air tract. Hyperemia 
of the upper respiratory tract and lingual varix are commonly 
associated with constipation, and indicanuria induces nasopharyn- 
geal congestion. Obstinate nasopharyngitis is observed in connec- 
tion with Glenard's disease. 

(/) Liver. — The nasopharyngeal mucosa is often congested 
in advanced cirrhosis of the liver. Ecchymoses and alarm- 
ing epistaxis are commonly observed in cirrhotic patients. In 
chronic jaundice the time required for coagulation of the blood to 
take place may be lengthened from three and a half to four and a 
half minutes (normal) to eleven or twelve minutes; hence the tend- 
ency to hemorrhage of the mucous membranes. The danger of 
operating in this condition is, therefore, considerable, because of 
the difficulty of controlling hemorrhage. 

The vascular, lymphatic and nerve interrelationship which 
exists between various organs of the body is still further illustrated 
by the manner in which toxins and infections are conveyed from 
the diseased to the healthy; thus infections of the ear, nose, and 
throat evoke cervical adenitis ; the appearance of asthma in con- 
junction with vasomotor rhinitis, arthritis from infected tonsils, 
and the simultaneous appearance of streptococcemic appendicitis 
and tonsillitis. 

(g) The Lungs. — Various diseases when appearing primarily 
in the lungs evoke secondary manifestations in the nose and throat. 
Among these are pulmonary tuberculosis, which has heretofore been 
considered (Chapter XXTX). Acute and chronic bronchitis and 
pleuritis induce secondary laryngitis and pharyngitis, partly from 
the mechanical irritation produced by coughing and from the infec- 
tion and irritation of the secretions. 

An excessive paroxysmal cough often induces hemorrhage from 
the nose, pharynx, or larynx, but, unless there is some ulceration or 



484 INFLUENCE OF GENERAL DISEASES. 

tumor to account for it, the amount is slight. Occasional cases 
of laryngeal ulceration have been reported in bronchopneumonia. 
A metallic cough and laryngeal paralysis (either abductor or com- 
plete) of the cords may occur in chronic thickening of the pleura, 
due to involvement of the recurrent laryngeal nerve, or in apical 
fibrosis of the right lung. 

The same symptoms are also observed in some cases of 
enlarged bronchial lymph glands, or from tumors in the upper 
mediastinum. Thymic enlargement in infants evokes characteristic 
stridor, and sometimes, during anesthesia, sudden death. 

ASTHMA. 

Asthma is of reflex nasal origin when due to septal deflections, 
hypertrophic rhinitis, ethmoiditis, and nasal polypi. This is believed 
to result from the intimate relationship existing between the vagus 
and the bulbar nuclei of the fifth nerve. This type of asthma is 
relieved and often cured by the removal of the intranasal lesion. 
The author cannot commend the universal cauterization of the 
upper portion of the triangular nasal cartilage in all cases of asthma 
as recommended by Francis and others. 

The theory advanced by Sajous 3 as to the etiology of asthma is 
ingenious and is freely quoted in the following remarks upon 
etiology and pathology : — 

Etiology and Pathogenesis. — According to Sajous, the predis- 
posing cause of asthma is an excessive irritability of the trigeminal 
centre in the pituitary body, due to the presence in the blood of 
toxic waste products. The presence of these toxic wastes is in turn 
the result of hypoactivity of the adrenal s} r stem, a condition which 
may be either inherited or brought on by disease of an adynamic 
type, especially those of childhood. The proportion of adrenoxidase 
formed being inadequate, catabolism is carried on imperfectly, and 
the intermediate wastes that are constantly present in the blood 
sustain the hypersensitiveness of the trigeminal centre. 

As a result of this trigeminal oversensitiveness, the mucous 
membranes, particularly those nearest the pituitary body, i.e., the 
nose (when the seat of local lesions, hypertrophies, polypi, 
exostoses, etc.), especially the eyes, pharynx, ear, and in some cases 
the entire respiratory tract, are hyperesthetic. 

HYPERESTHETIC RHINITIS 
(Hay Fever, Rose Cold, Autumnal Catarrh, etc.). 

This affection, commonly known as hay fever, is found in 
certain persons of neurotic constitution and hyperesthetic nasal 
mucosa in whom certain irritants in the form of pollens, or irritat- 
ing emanations produce periodical attacks of a severe form of acute 
obstructive rhinitis with asthmatic symptoms. 



3 Internal Secretions and the Principles of Medicine, p. 1711. 



ANGIONEUROTIC EDEMA. 485 

Treatment (See Allergy and Pollen-therapy, p. 646). — The cor- 
rection of nasal deformities, the removal of polypi, and the eradication 
of diseased turbinals and accessory sinus affections is indicated in all 
cases of asthma. As a preventive measure Sajous recommends the ad- 
ministration of thyroid extract in 3-grain doses three times a day, to be 
reduced to 2 grains twice daily after four days, this treatment to be 
commenced about four weeks before the usual onset of periodical attack. 

Treatment by the various specific sera has not met with general 
success. In America the usual irritant is the pollen of the rose, rag- 
weed, and goldenrod, while in Europe it is more often that of the 
grain-bearing grasses. This may account for the greater success 
from the administration of Dunbar's serum abroad, as it is made 
from the grain pollen. Somers reports some success from the use 
of the goldenrod antitoxin. Michaels, Braden Kyle, and others have 
investigated the chemical changes in the nasal and buccal secretions 
in sufferers from hyperesthetic rhinitis, and contend that a subacid 
condition, due to faulty elimination, attended by excessive ammonia 
salt production is, in some instances, a source of irritation in hay 
fever. 

During the attack much relief is obtained by abstaining from 
alcohol, tobacco, rich foods and by a careful observance of recog- 
nized rules of hygiene. The nasal mucosa may be cleansed with 
bland alkaline sprays and protected by liquid vaselin, which may be 
medicated with camphor and menthol, 2 per cent. 

A spray of 2 to 4 per cent, cocaine and 1 : 5000 adrenalin by 
contracting the arterioles gives temporary relief. To some patients 
adrenalin is extremely irritating, and in these its local use aggra- 
vates the symptoms. 

The administration of thyroid extract, grs. iij, is worthy of 
trial, and codeine taken at night is beneficial. Excitement and over- 
exertion should be avoided. Of all forms of treatment the climatic 
is the most successful. 



ANGIONEUROTIC EDEMA. 

Angioneurotic edema is characterized by the appearance of 
circumscribed swellings upon the skin or mucous surface, which are 
the result of vasomotor neuroses. 

It is a rare disease which may appear upon any portion of the 
surface of the body. It occasionally develops in the mucosa of the 
pharynx or larynx. The edematous patches are pearly gray in 
color, non-inflammatory, and are not attended by febrile symptoms. 
They appear suddenly, and after from one to three days subside. 
In the pharynx angioneurotic edema rarely produces serious symp- 
toms, but in the larynx the edematous tissue may produce serious 
dyspnea or asphyxiation. 

The treatment of this disease is precisely the same as that 
indicated for infectious epiglottitis (Chapter XLVIII). 



486 



IXFLUEN'CE OF GENERAL DISEASES. 



CIRCULATORY SYSTEM. 

In all diseases of the heart, whether primary or secondary, 
where the compensation is insufficient there exists a tendency to 
congestion of the mucous membranes and tissues of the head. In 
the upper respiratory tract epistaxis, labyrinthine and other hemor- 
rhages occasionally result. Edema of the larynx is sometimes of 
cardiac origin. Whenever left abductor laryngeal paralysis com- 
plicates severe pericardial effusion it is due to pressure on the left 
recurrent laryngeal nerve. Aneurisms in the thorax frequently 
cause laryngeal paralysis and aphonia by pressure upon the recur- 
rent laryngeal nerve. Aneurism of the aortic arch usually involves 




Fig. 301. — The Faught blood-pressure apparatus. 

the left recurrent laryngeal nerve. Aneurism of the ascending por- 
tion of the aorta by extending into the right pleura may finally 
involve the right recurrent laryngeal nerve. Occasionally both 
nerves are involved. Aneurism of the subclavian artery may also 
cause paralysis of the larynx. Paralysis of the left vocal cord is 
commonly the first symptom induced by aneurism of the arch of 
the aorta. 

Malignant endocarditis has been traced in some cases to strep- 
tococcic tonsillitis. High blood-pressure in arteriosclerosis may 
produce nausea, headache, vertigo, and tinnitus. If this occurs in 
one with considerable deafness, labyrinthine disease may be 
wrongly inferred. The sphygmomanometer (Figs. 301 and 302) 
serves to verify the diagnosis. Vasodilators are the appropriate 
remedial agents. Labyrinthine hemorrhage is more common in 
individuals with atheromatous arteries. 

(a) Anemia. — Anemic symptoms are apparent earlier and are 
more pronounced in the nose than in the conjunctiva, lips and 



CIRCULATORY SYSTEM. 487 

gums. It is characterized by a shrunken and pale appearance. 
Olfactory hallucinations and tinnitus aurium are common in 
anemia when due to sudden hemorrhage. Anemia- of the soft palate 
and epiglottis is characteristic of advanced phthisis. The pharyn- 
geal mucosa in anemia is pale and either hyperesthetic or anesthetic, 
while the voice may become functionally weak, husky, or even 
aphonic. In severe anemia ecchymotic spots and various hemor- 
rhages of the mucosa are quite common. Labyrinthine hemorrhage 
may occur in pernicious anemia. 




Fig. 302. — The Faught blood-pressure apparatus applied 
to a patient's arm. 

(b) Leukemia. — The complications of leukemia found in the 
nose, throat, and ear are cancrum oris, inflammation of the tonsils 
and pharynx, often with necrotic areas, epistaxis, hemorrhage into 
the tympanum or labyrinth, and deafness. Vidal. and Isandert 
found disturbances of hearing in 10 per cent, of all cases of leuke- 
mia. Schwabach states that in acute leukemia deafness arises in 
the initial stages, while in the chronic form deafness appears in the 
later stages. 

In various forms of purpura, whether toxic, neurotic, in the 
newborn or in hemophiliacs, and purpura hemorrhagica, surgical 
operations are extremely dangerous. Attempts have recently been 
made to increase the coagulation of the blood by the subcutaneous 
injection of a serum, or by the direct transfusion of the blood of a 
normal individual. 



488 INFLUENCE OF GENERAL DISEASES. 

HODGKIN'S DISEASE. 

During an attack of Hodgkin's disease the mucosa is often 
waxy and pale yellow in appearance. Epistaxis and other hemor- 
rhages are not so frequent as in leukemia. In severe cases lymph 
nodules appear on the tonsils, epiglottis, aryepiglottic folds, and 
sometimes in other parts of the larynx and trachea. They appear 
as small, soft, whitish, and slightly raised spots, with a tendency to 
necrosis and ulceration. Extensive infiltration and sometimes large 
tumors appear in the tonsils and in other parts of the pharynx or at 
the base of the tongue. Involvement of the bronchial glands may 
cause laryngeal paralysis through pressure upon the recurrent 
laryngeal nerve, or pressure symptoms may be produced on the 
bronchi or trachea. 

TABES DORSALIS 
(Locomotor Ataxia). 

Tabes dorsalis is attended with several symptoms which are 
referable to the throat and larynx, the most common of which is 
paralysis of the laryngeal muscles. -The abductor muscles are the 
first to succumb, but in advanced cases the tensors also may become 
involved. Complete recurrent paralysis is rare. 

Laryngeal paralysis is often the earliest symptom of tabes, 
and according to Watson Williams is always accompanied by 
marked and persistent increase in the pulse rate. 

Laryngeal crises is a later symptom of tabes and is charac- 
terized by paroxysms of coughing, which are immediately followed 
by dyspnea. Violent rasping cough and strident inspiratory sound, 
together with the excitement due to the patient's fear of impending 
suffocation, produce an alarming series of symptoms. Respiration 
finally ceases temporarily, and the patient may lose consciousness 
or complain of vertigo. The attack usually lasts about thirty 
seconds, after which the respirations become normal. Fatal cases 
of laryngeal crises have been reported. 

Regarding laryngeal crises, Touche found 12 cases in 40 cases 
examined. Green found 7 out of 60 cases examined. Moore and 
Martin report fatal cases of recurrent laryngeal spasm, complicated 
by bronchial spasm. In both cases tracheotomy was performed, 
but death from exhaustion ensued in about ten days. Whenever 
there is lack of co-ordination of the muscular movements of the 
larynx, ataxic movements of the cords may be seen, in consequence 
of which the speech becomes jerky and uncertain. Anesthesia and 
hyperesthesia of the pharynx and larynx is occasionally observed 
as a complication of tabes. Paresthesia is more rare. 

Progressive deafness, according to Duchenne, is common in 
locomotor ataxia, and is due to atrophy of the acoustic nerve. 
Morepurgo and Marina examined S3 tabetics and found only 10 
who had normal hearing. According to Politzer, tabes is accom- 
panied by unbearable tinnitus, the disease being bilateral and often 
accompanied by vertigo. 



PREGNANCY. 439 



SCURVY. 

In scurvy the gums are swollen, edematous, or ulcerated and 
bleed easily; the teeth are foul and become loose or fall out. The 
tongue may be swollen. Hemorrhagic areas which tend to ulcerate 
sometimes appear in the mouth or pharynx. 



UREMIA. 

The lowered resistance of the body which accompanies ad- 
vanced kidney lesions tends to aggravate all forms of aural affec- 
tions. 

A special uremic stomatitis has been described by Barie. It 
occurs on the lips, gums and tongue, which become swollen and 
ulcerated with increase of saliva. 



CHRONIC INTERSTITIAL NEPHRITIS. 

Edema of the glottis, epistaxis, tinnitus, vertigo, and deafness 
are observed in chronic interstitial nephritis and less commonly in 
parenchymatous nephritis. 



GENITAL SYSTEM. 

Periodic hyperemia of the nasal mucosa, turgescence of the 
inferior turbinals, epistaxis, hyperesthesia, and paresthesia are 
sometimes observed in conjunction with disturbances in the genital 
tract in both males and females. Voice weakness and slight hoarse- 
ness sometimes occur in female singers at the menstrual period. 
According to Meniere and Jacobson, sudden cessation of menstrua- 
tion may produce labyrinthine hemorrhage. Vicarious bleeding 
from the external auditory canal has been reported in a few 
instances, and more commonly from the nose and throat. Laut- 
mann and Fliess claim to have found hyperesthetic points on the 
inferior turbinal and septum in dysmenorrhea. Bettmann reports 
a case of labial and laryngeal herpes appearing regularly one week 
prior to the menstrual flow. 

PREGNANCY. 

The influence of pregnancy on tuberculosis of the larynx is 
baneful. In a series reported by Kuttner, 200 out of 231 died during 
or shortly after delivery. Freudenthal 4 reports a similar experience. 
Furthermore about 7? per cent, of children born of mothers who 
have tuberculous laryngitis die within the first year. 



4 Transactions of the American Laryngological, Rhinological and Otological 
Society, 1907, p. 274. 



490 INFLUENCE OF GENERAL DISEASES. 

PUBERTY. 

There is a marked growth and development of the upper 
respiratory tract, especially in the male, at puberty, with a tendency 
to congestion of the mucosa. The accessory sinuses may also grow 
rapidly at this time, and adenoids of moderate size which previously 
obstructed respiration may now, owing to increased size of the 
nasopharynx, no longer interfere. At this period the vocal cords 
increase markedly in length in the male ; not so much in the female. 
This explains the breaking of the boy's voice at this period. The 
laryngeal muscles become easily fatigued ; therefore, squeaking and 
hoarseness are easily evoked. The "change of voice" requires about 
one year. Occasionally the voice becomes temporarily or perma- 
nently falsetto, especially if much used in singing at this time. 
Persistent falsetto is treated by vocal and respiratory exercise, such 
as deep and slow respirations and production of deep tones several 
times a day. Later, words should be pronounced deeply and slowly, 
gradually lengthening the exercises until reading aloud may be em- 
ployed. In two or three weeks a cure is effected. 

STATUS LYMPHATICUS. 

Status lymphaticus, so named by Paltauf, is characterized by a 
persistent or hypoplastic thymus gland, associated with hyperplasia of 
the tonsils, adenoids, lymph-nodes, lymphatic elements of the intes- 
tinal tract and spleen. The importance of status lymphaticus in dis- 
eases of the upper air tract is due to the liability of the victims of this 
diathesis to suddenly die during the administration of anesthesia, espe- 
cially chloroform. Fatalities have also been known to follow sudden 
shock and injection of diphtheria antitoxin. Cocks 1 has reported an 
interesting series of cases and calls attention to the significance of 
dyspnea and stridorous breathing in newborn children. It often hap- 
pens that the presence of status lymphaticus first becomes apparent 
when anesthesia has been induced and alarming or fatal results have 
ensued. The diagnosis is difficult, although percussion of the enlarged 
thymus gland may be of some benefit. Radiography (Fig. 302a) seems 
to offer the surest diagnostic evidence of this affection. There is no 
known treatment for this diathesis, but it is here suggested that in 
cases of known status lymphaticus, anesthesia, particularly chloroform 
narcosis, should be avoided. Where the dyspnea has been due to the 
mechanical pressure of the enlarged thymus gland upon the trachea. 
Jackson and others have excised a portion of the gland, or have pulled 
it forward and sutured it to the sternum, after the preliminary per- 
formance of tracheotomy with a tube long enough to reach below the 
obstruction. 



i The Laryngoscope, July, 1910 ; August, 1912. 




Fig. 302a. — Loaned by Dr. John E. MacKenty, with the following 
history: Child aged 3 years, normal at birth. Shortly after birth began 
to lose weight, but was restored by mercurial inunctions. In August, 1912, 
was given antitoxin for an attack of diphtheria and the larynx was in- 
tubated. The tube was kept in for six weeks. Obstructed dyspnea re- 
mained until December. Child is anemic; nutrition is defective; pulse 
accelerated, but temperature normal. There is retraction of the lower cos- 
tal region and supraclavicular spaces on inspiration. Expiration from left 
lung prolonged and whistling, due probably to pressure on left bronchus. 
In the radiograph the arrows point to the outer borders of the enlarged 
gland, which extends to and ovcrlapscs the .aorta and heart. 



PART III. 

The Nose and Accessory Sinuses. — The Pharynx 
and Fauces. — The Larynx. 



SECTION I. 

The Nose and the Nasal Accessory Sinuses. 



CHAPTER XXXIII. 

ACUTE INFLAMMATORY AFFECTIONS OF THE 
NASAL MUCOSA. 



RHINITIS. 

General Remarks. — This extremely common affection both in 
its acute and chronic form was believed by Galen to be the result 
of a secretion from the brain passing through the orifices of the 
ethmoid into the nose, the process relieving the brain of superfluous 
substances. Schneider successfully combated this theory, and after 
him the nasal mucous membrane is sometimes called the Schnei- 
derian membrane. In France a cold in the head is still designated 
rheume de cervcaux. During later years, as the result of patholog- 
ical study, a more intelligent classification has been rendered pos- 
sible, showing the variety of diseases which may be, generally, 
classified under the term rhinitis. 

Pertaining to the probable bacterial origin of intranasal dis- 
eases, it may be stated that, aside from the air-borne organisms with 
which the vibrissa? are contaminated, the organisms found most 
frequently in inflammatory conditions of the mucous membrane of 
the nose are the diphtheria bacillus, the influenza bacillus, the 
Micrococcus catarrhalis, and less commonly the pneumococcus. In 
suppuration of the accessory nasal cavities the bacteriology varies. 
In antrum disease the micro-organisms are numerous, with the 
Bacteria fusiformis predominating when the infection is from carious 
teeth ; the other bacteria found are the pneumococcus, streptococcus, 
staphylococcus, and the Micrococcus catarrhalis. Often these can 
be found in pure culture. 

The nasopharynx mav harbor this same variety of micro- 
organisms, with the addition of the meningococcus, and frequently 
without exhibiting any pathological features until the tissue resist- 
ance is lowered or the increase in bacterial virulence may arouse 
them into activity. While the subject has not, as yet. been suffi- 

(491) 



492 NOSE AND NASAL ACCESSORY SINUSES. 

ciently investigated to point to a positive bacteriology of the 
majority of the diseases of the nose and the accessory cavities, still 
the specific organisms of some of the infectious diseases affecting 
the nasal cavities are readily isolated, as the tubercle bacilli in 
tuberculosis and lupus, the Spirochcta pallida in syphilis, the Bacillus 
lepra in leprosy, the bacilli of Frisch in rhinoscleroma, the Bacillus 
mallei in glanders, and Klebs-Loeffier bacilli in diphtheria. 

The various forms of rhinitis may be classified under two 
general headings, viz., acute and chronic. 

SIMPLE ACUTE RHINITIS 
(Acute Coryza, "Cold in the Head"). 

Acute nasal catarrh is an inflammatory process involving the 
nasal mucosa, with an accumulation of lymphocytes in the tissues 
surrounding the blood-vessels. This accounts for the copious 
exudate which accompanies the disease at times, and the congestion 
is of sufficient severity to produce capillary rupture and extravasa- 
tions. 

Etiology. — The predisposing causes of simple acute rhinitis are 
physical exhaustion, chronic rhinitis, constitutional disorders, age, 
heredity, and bad hygiene. Individuals who suffer from chronic 
rhinitis resulting from intranasal obstruction are extremely liable 
to attacks of simple acute rhinitis. 

Among the constitutional disorders which predispose to this 
affection are the gouty diathesis, rheumatism, diabetes, dyspepsia, 
asthma, cardiac diseases, and Bright's disease. Physical exhaus- 
tion, whether from overwork, dissipation or disease, creates a sus- 
ceptibility to attacks of simple acute rhinitis. Likewise the 
deterioration of health which follows prolonged association with 
insanitary surroundings strongly predisposes to this affection. 

"We mention, as examples of the latter, vitiated air, overcrowd- 
ing, defective diet, insanitation, sedentary habits and neglect of 
body cleanliness. Of the exciting causes, chemical irritants, 
exposure to cold, dampness, and, according to Parker, extreme heat, 
or to bacterial irritants (infections) are the most noteworthy. 
Furthermore it is significant that simple acute rhinitis is more 
common during the change of seasons. 

No specific germ has yet been isolated, but its bacterial nature 
is undoubted, since in most cases the Bacillus influenza, the Micro- 
coccus catarrhalis, and Friedlander's bacillus are found. 

Bacteria within the nasal cavities may long remain inactive; on 
the contrary, however, they may rapidly develop pathogenic proper- 
ties provided favorable conditions appear in the way of circulatory 
disturbances in the nasal mucous membrane, or when the general 
health is below par, thus lowering the bodily resistance. 

It is doubtful whether micro-organisms alone ever primarily 
give rise to simple acute catarrhal rhinitis, and it is still a disputed 
point whether the other etiological factors heretofore named may 
excite an attack without the influence of micro-organisms. 



RHINITIS. 493 

Frequent attacks during childhood signify the presence of hyper- 
trophic lymphoid tissue in the nasopharynx. 

Pathology. — The pathological changes may be classified accord- 
ing to three clinical stages of the disease, (a) Initial stage or onset. 
The onset of simple acute rhinitis is characterized by sudden con- 
gestion of the capillaries of the nasal mucosa, accompanied by dry- 
ness, swelling, a shiny appearance and reduced secretion. (b)" 
During the second stage infiltration of the mucosa becomes more 
marked and the secretions more profuse, the latter at first being 
serous and gradually becoming mucopurulent as the third stage is 
reached. Meanwhile the nasal passages become "stuffed" or 
blocked as a result of the tumefaction of the mucous membrane and 
turbinal tissues, (c) The third stage is marked by gradual cessation 
of the injection and infiltration of the mucosa, and by profuse muco- 
purulent or purulent discharge. In neglected cases the third stage 
may be prolonged indefinitely, and gradually assume the charac- 
teristics of chronic catarrh. Otherwise the secretions gradually 
subside and the mucosa returns to the normal state. 

Symptoms. — An attack of acute rhinitis is usually ushered in 
by sneezing and a sensation of nasal stuffiness or obstruction. The 
obstruction is associated with a burning sensation in the nose, ten- 
derness over the forehead upon pressure, heat in and below the eyes, 
lachrymation, a general sense of dryness of the mouth and throat, 
and often perversion or absence of the sense of smell and taste. 
Soon after the onset the general symptoms supervene, such as 
languor, fatigue, chilliness, and prostration. The general disturb- 
ances may be slight, but very commonly they are prolonged and 
distressing on account of the predominance of one or more of these 
manifestations. After a few hours the nasal obstruction becomes 
associated with a profuse watery discharge and the mucosa which 
was at first hyperemic becomes so much infiltrated that one or both 
nostrils may become entirely occluded. The nasal obstruction com- 
monly alternates from one nostril to the other. The serous exudate 
soon changes to a mucopurulent and therefore thicker discharge as 
a result of the increasing admixture with cellular elements, and 
meanwhile it diminishes in quantity. The discharge often possesses 
an irritating quality which produces excoriation -of the skin about 
the nasal orifices and upper lip. There may be a slight rise of 
temperature and considerable loss of appetite. On account of the 
interference with taste and smell, habitual users of tobacco usually 
abstain voluntarily during this period. Mouth-breathing is the rule, 
especially during sleep, resulting in great dryness of the pharyngeal 
and laryngeal mucosa. Nursing children, on account of the attend- 
ant nasal obstruction, encounter much difficulty in taking nourish- 
ment, being frequently obliged to drop the nipple in order to 
breathe. The swelling of the mucosa gradually subsides, and the 
secretion slowly diminishes and finally disappears; the attack 
usually terminates after a week or the proverbial nine days. 

Complications. — Occasionally the disease extends over a period 
of several weeks, especially the influenzal forms, or when com- 



494 NOSE AND NASAL ACCESSORY SINUSES. 

plicated by involvement of the accessory sinuses or the middle ear, 
or of the pharynx or larynx. The nasopharynx is almost invariably 
involved in every case, and an associated acute tonsillitis is common. 
Simple acute rhinitis is quite often secondary to an attack of acute 
tonsillitis. Sometimes the catarrhal affection in the nose shows a 
marked tendency to extend to the deeper air passages, even to the 
bronchi. In certain individuals an attack of simple acute rhinitis 
predisposes to prolonged bronchial inflammation. The disease also 
may extend to the lachrymal ducts and the conjunctiva, and often 
involves the Eustachian tube, thus producing temporary obstruction 
of its calibre and consequent acute catarrhal otitis media (see Chap- 
ter XVI). A prolonged purulent involvement of the nasal accessory 
sinuses occasionally persists, requiring special treatment in order to 
prevent chronic empyema of these cavities. These complications 
are more prone to occur in the influenzal forms, to be described 
later. 

Treatment. Prophylaxis. — Frequent attacks of simple acute 
rhinitis, especially in adults, demand the inauguration of stringent 
preventive measures. The following remarks relating to the general 
care of the body are appropriate in their relation to taking cold : — 

An ordinary draft of air in a room never should induce an 
attack of acute rhinitis in a person who habitually practises proper 
hygienic health measures, and one who fears such exposure con- 
fesses to a lack of resistance which is incompatible with good 
health. The efforts of all individuals, and especially those who 
abide in changeable climates, should be to fortify the resisting 
power of the body; in other words, to develop resistance rather 
than to attempt prevention by means of "coddling" habits, either 
during childhood or adult life. For this purpose a morning applica- 
tion of cold water to the body, either in the form of a sponge, spray, 
or plunge, is highly recommended. Most healthy individuals react 
readily and promptly from a sudden plunge into cold water, and 
in a considerable proportion the reaction takes place without 
rubbing with a towel. Nevertheless much benefit arises from fric- 
tion, induced by rubbing the entire body with a coarse bath towel 
immediately after the bath. 

The cold bath is contraindicated in persons who for any reason 
do not react after friction is applied to the surface. To those 
unaccustomed to its use and who desire to commence the daily 
morning bath, the temperature of the water for the first few days 
should be moderate and gradually lowered each morning until the 
proper temperature for quick reaction has been reached. Further- 
more the brisk rubbing benefits the capillary circulation. 

The morning use of cold water may safely be commenced in 
children as young as two years, and this procedure should become 
a part of the daily habit of all children who are free from constitu- 
tional affections. The tonic effects are most marked and the 
tendency to colds proportionately reduced as the body can 
accustom itself to the sudden application of cold water. One who 



RHINITIS. 495 

can safely resist the shock of the cold plunge or even that of spong- 
ing may with impunity and confidence expect to resist ordinary 
drafts and exposure. 

Bo"dily resistance is also considerably influenced by the quan- 
tity and texture of clothing worn. The clothing should be judi- 
ciously selected to meet the requirements of the locality, occupation 
and the degree of exposure. The clothing of persons with indoor 
occupations should differ materially from that worn by those with 
outdoor occupations. In this connection it may be stated that 
excessive clothing may do as much harm as insufficient. When- 
ever the occupation requires indoor life, the undergarments should 
be of light weight, to be supplemented by heavy outer garments 
when going out of doors. It is not wise to wear heavyweight 
woolen undergarments in occupations unattended by undue ex- 
posure; light wool will usually suffice. Of late the linen-mesh 
underwear has obtained considerable popularity, upon the theory 
that bodily moisture rapidly passes through this fabric. 

Protection of the feet from dampness and cold is of great 
importance. Whenever the streets or sidewalks are wet or slushy, 
rubbers should be worn to protect the feet from dampness. 
Exposure to drafts does not induce colds in the same proportion 
as does the neglect to protect the feet from cold and dampness. 

The prolonged inhalation of vitiated air should also be avoided. 
All occupied rooms and particularly sleeping apartments should be 
sufficiently ventilated .to insure the proper amount of oxygen. 

The air of a sleeping apartment should be fresh, and on account 
of warm bed covering, the temperature may safely be lowered to 
50° or even lower. In extreme weather the temperature of the 
sleeping apartment can be controlled by allowing sufficient heat to 
enter the room. 

Bodily exercise promotes resistance and thus tends to prevent 
colds. A brisk walk to and from business or at the lunch hour, 
accompanied by deep breathing, is of great benefit, ""although every 
individual, if possible, should at regular intervals indulge in more 
fatiguing and general muscular exercise. The gymnasium with its 
variety of implements for indoor exercise, bicycling, walking, hunt- 
ing, horseback riding, golf and tennis for outdoor exercise are 
examples of healthful and helpful methods to be employed, always 
bearing in mind that free perspiration is of great benefit to the 
human economy. Even the gymnasium can be dispensed with by 
employing a few forms of muscular exercises in one's own home. 
No person may expect to maintain perfect health who refrains from 
systematic physical exercise. 

General and Local Treatment. — It is extremely difficult to 
induce persons suffering with acute rhinitis to submit to the form 
of treatment which mitigates its severity, lessens its duration and 
almost surely guarantees immunity from troublesome and even 
severe or serious complications. As a rule, patients know that the 
disease is self-limited, that in a large proportion of cases serious 



496 NOSE AND NASAL ACCESSORY SINUSES. 

complications do not occur, and they unwittingly run risks by 
attending to their usual duties, and only those who are prone to 
prolonged complications are willing to submit to the necessary 
restrictions and medication. Elderly persons should invariably 
remain indoors during the active stages of acute rhinitis. 

At the onset, in individuals who consent to remain in bed, or 
at least indoors for two or three days, by taking a hot mustard 
footbath, a draught of hot lemonade and ten grains of Dover's 
powder, sweating is induced and the symptoms are ameliorated. A 
saline cathartic should be administered on the following morning. 
This form of medication is hardly to be recommended except during 
the early stages, after which the indications are for the relief of the 
obstructive turgescence, the cleansing of the nose and nasopharynx, 
and the prevention of complications. At this stage it is still 
desirable that the patient abstain from work and remain indoors. 
The internal administration of extract of belladonna, grain ]/%, 
every two or three hours, or atropine, grain Yi2o, at the same inter- 
vals until cessation of the coryza ensues, will be found of consider- 
able benefit. The administration of quinine, in doses of from 2 to 5 
grains three times a day, is useful in shortening the attack. 

For the temporary relief of the turgescence of the mucous 
membrane, the local application of adrenalin to be used in the form 
of a spray in strength of 1 : 5000, the dilutions being made with 
normal salt solution, is recommended. With such a solution the 
entire nasal mucosa may be freely sprayed at intervals of from one 
to three hours in order to relieve the stenosis. Unfortunately in a 
considerable proportion of patients this medicament evokes severe 
sneezing and aggravates the coryza. In these it should not be 
employed. 

That the effect is not permanent is well known ; nevertheless 
the patient is able to breathe and sleep comfortably, and no deleteri- 
ous effects result from its use. One marked advantage gained is 
the complete and thorough washing out, at frequent intervals, of 
the pent-up secretion, which undoubtedly carries away a preponder- 
ance of the micro-organisms. 

After the tissues have contracted and the secretions have been 
blown out, it is advisable to spray the mucous membrane with some 
form of oily medicament. The O. B. Douglas formula of benzoinol 
possesses many virtues for this purpose : — 

B Thymol gr. x. 

Eucalyptol gtt. xx. 

Menthol gr. xxx. 

Ol. cubebs gr. xl. 

Benzoinol 3iv. 

Oil rose q. s. 

The De Vilbiss hand atomizer (Fig. 303) is a convenient, 
serviceable, and reliable spray apparatus. 

The oil produces a soothing effect upon the mucous membrane 
and it also tends to counteract the irritation of the skin surround- 



RHINITIS. 497 

ing the nose caused by the discharge. It is neither necessary nor 
advisable to employ cocaine during an attack of coryza, and patients 
never should be allowed to make use of it in any form, on account 
of its depressing effects and the attendant danger of forming the 
cocaine habit. The two above-named local applications are suffi- 
cient for all requirements until the active symptoms have passed, 
when for some days it may be necessary to wash away surplus 
secretions. Non-irritating simple alkaline sprays (pulv. alkali 
antiseptic, N. F.) or normal physiological salt solution may be used 
for this purpose. 

RHINITIS OF INFLUENZA (LA GRIPPE) 

is an acute rhinitis resulting from a bacterial invasion, either 
of the influenza bacillus (Pfeiffer bacillus) or the Micrococcus 
catarrhalis, is always of a severe type, and accompanies the majority 
of cases of influenza or grippe. 




Fig. 303.— The DeVilbiss hand atomizer. 

The symptoms do not differ essentially from those of ordinary- 
acute rhinitis. Added to these, however, are the profound con- 
stitutional effects of the disease itself as manifested in the high 
temperature, severe pain, profound depression, and exhaustion. The 
presence of the streptococcus along with the influenza type of infec- 
tion, with its tendency to rapid invasion, renders the grippal form 
of rhinitis extremely liable to extend to the accessory sinuses of 
the nose, the middle ear, and downward into the larynx, trachea, 
bronchial tubes, and pulmonary lobules. During epidemics of 
influenza the more severe types of accessory-sinus infection are 
observed. Middle-ear suppuration, also of a severe type, often 
accompanied by rapid extension into the mastoid process, and even 
to the meninges, is prone to occur. It must be emphasized that in 
any case of grippe the accessory sinuses and the middle ear should 
be carefully and persistently watched, so that the first advent of 
any involvement of the same may be noted. 

Treatment. — Much has been written in regard to the general 
treatment of this affection, but, so far as the inflammatory condi- 
tions of the upper air passages are concerned, it may be stated, in a 
general way, that rest in bed is of the utmost importance and it 
should be insisted upon in all cases. Free catharsis and the adminis- 
tration of 5-grain doses of aspirin every four hours, or a sufficient 
amount of salol and phenacetin to control the pain — usually 2y 2 

32 



498 NOSE AXD NASAL ACCESSORY SINUSES. 

grains of phenacctin with 5 grains of salol every hour for three or 
four hours — will suffice, after which time the dose may be repeated 
at intervals of three to six hours when necessary. The immersion 
of the feet in hot mustard water at the commencement is of bene- 
ficial effect in relieving the intense turgescence of the nasal mucosa. 
At all times the secretions from the nose and nasopharynx should 
frequently be washed away, precisely as in simple acute rhinitis, 
care being taken to advise patients to avoid forcible blowing of the 
nose, an act which is liable to force infection into the Eustachian 
tube-. 

Sinus involvement should be treated as laid down in the 
chapters on diseases of the nasal accessor}" sinuses and an infectious 
grippal otitis media as advised in Chapter XVIII. 

RHINITIS OF THE ACUTE EXANTHEMATA AND OTHER 
SYSTEMIC INFECTIONS. 

The rhinitis accompanying the acute exanthemata and other 
systemic infections is mentioned in Chapter XXXI, but we reaffirm 
that it is unusually severe, especially in measles, and should receive 
special treatment from the very commencement of the disease. In 
measles the turgescence of the mucosa is sufficient to materially 
affect nasal respiration and phonation, and it is the chief symptom 
noticeable during the stage of invasion. This is invariably accom- 
panied by rise of temperature, cough, congestion of the conjunctiva, 
more or less headache, and occasionally nausea. These symptoms 
usually precede the appearance of the characteristic rash by two to 
four days. The symptoms are present, but less marked and less 
permanent with pertussis, scarlet fever, and other infectious dis- 
eases. Of late much has been written concerning pansinusitis as a 
complication of measles and scarlet fever, particularly the latter. 

DIPHTHERITIC RHINITIS. 
For detailed description see Chapter XXXT. Diphtheritic 
rhinitis is sometimes observed as an accompaniment of faucial 
diphtheria. Occasionally nasal diphtheria occurs primarily, and 
then the diphtheritic membrane limits itself to the nasal mucosa. 
It may exist for a considerable period, its exact nature being 
revealed only upon a careful inspection of the nasal cavities and an 
examination by culture for the Klebs-Loeffler bacillus. The treat- 
ment is the same as for faucial diphtheria, antitoxin, etc. (see 
Chapter XXXI). 

MEMBRANOUS RHINITIS. 

Membranous rhinitis is an inflammation involving" the mucosa 
of the nasal cavities, which results in a membranous formation that 
involves not only the epithelial, but also the subepithelial portions 
of the membrane. By many it is believed to be diphtheritic, but 
clinical experience, supported by microscopical findings, whereby 
it is shown that many cases occur without the presence of the 



RHINITIS. 499 

Klebs-Loeffler bacillus, would seem to indicate that this disease 
may occur independently of diphtheria. Individuals living in badly 
ventilated, damp and otherwise unhygienic quarters are peculiarly 
liable to membranous rhinitis. It sometimes occurs as a result of 
traumatism and severe irritants. 

Locally, hydrogen dioxid in dilution 1 to 3, used as a spray 
or alkaline antiseptic douching, will separate the false membrane. 
Occasionally, however, it becomes necessary to gently remove por- 
tions of the membranous tissue, which may relieve the obstruction 
for a time. 

Inasmuch as membranous rhinitis is most prevalent in chil- 
dren of a lymphatic or rachitic type, dietetic and tonic treatment 
is the most beneficial in these cases. Syrupus ferri iodidi et syrupus 
calcii lactophosphas are the best internal remedies. ' 

ACUTE RHINITIS DUE TO LOCAL SPECIFIC INFECTIONS 

(Gonorrhea, Erysipelas). 

Gonorrheal rhinitis is always secondary. Young infants with 
gonorrheal ophthalmia occasionally are victims of the nasal form. 

For the treatment of the nasal involvement in gonorrheal 
rhinitis frequent applications of a 25 per cent, argyrol solution, 
after cleansing the nasal chambers with an alkaline or boric acid 
wash, will arrest the infection. For the control of treatment, the 
microscopic examination of smears from the discharge will reveal 
the presence or absence of Neisser's gonococci. 

Whenever erysipelas invades the nasal cavities it is liable to be 
accompanied by an acute rhinitis of unusual severity, which mani- 
fests a tendency to extend to contiguous membranes. High tem- 
perature is one of its marked symptoms. Facial erysipelas is 
supposed to have its infection atrium in an abrasion or fissure about 
the nasal vestibule. 

The general treatment of erysipelas is fully outlined on 
pages 100, 252, and 476. Locally, simple cleansing of the mucosa 
with non-irritating alkaline sprays affords relief to the distressing 
intranasal inflammation. 

ACUTE RHINITIS DUE TO CHEMICAL AND MECHANICAL 
(TRAUMATIC) CAUSES. 

Acute inflammation involving the nasal mucosa may result 
from the inhalation of poisonous or hot vapors or fumes, as from 
ammonia, the corrosive acids, iodin, bromin, etc., or vitiated air 
laden with irritating mineral and vegetable dust particles, or smoke, 
and usually is accompanied by a similar inflammatory condition 
along the entire respiratory tract. This, and the mechanical type 
have sometimes been referred to as "occupation rhinitis." The 
susceptibility of certain individuals is marked, especially to the 
gases in chemical laboratories, mines, foundries, artificial ice plants, 
and manufacturing establishments where chemicals are used in 
large quantities. After a prolonged sojourn in the pure air of the 



500 NOSE AND NASAL ACCESSORY SINUSES. 

country, patients returning to the city are prone to develop acute 
rhinitis of this type. 

In the acute rhinitis resulting from mechanical causes the 
inflammation arises from intranasal traumatism, either accidental 
or operative, or from the inhalation of dust-laden atmosphere in 
mines, granaries, mills, in wood sawing or carving" shops, in gold, 
silver and brass smithies, stone-cutting, and other irritating manu- 
facturing and industrial pursuits. 

Intranasal operations, the removal of septal spurs or turbinal 
hypertrophies, even when done under strict aseptic precautions, 
arc usually followed by sufficient reaction to produce more or less 
general inflammation of the nasal mucosa. 

Symptoms. — In the rhinitis due to chemical causes, such as the 
inhalation of noxious vapors and dust in the various pursuits 
enumerated above, the local symptoms differ from the acute type 
of rhinitis in that the} r come on suddenly, are more severe, and 
the nasal and lower respiratory tissues become edematous and 
obstructed. When the mucosa of the pharynx and the larynx 
becomes slightly edematous, mild dyspnea, cough and dysphagia 
are thereby induced. These symptoms come on rapidly, and, in the 
severer cases when accompanied by extensive edema which extends 
to the larynx, asphyxia is threatened. 

With the rhinitis caused by irritation from mechanical causes, 
the local nasal symptoms do not differ from those already discussed 
under the acute catarrhal variety ; but the accompanying inflamma- 
tory condition along the rest of the respiratory tract is of a slow, 
chronic type, with bronchial or pulmonary involvement, producing 
a form of pneumonokoniosis, associated with cough, expectora- 
tion, and emaciation. 

Diagnosis. — In these cases a diagnosis is readily made from 
the history of the case and by inspection. 

Prognosis. — In the severe type (chemical) the prognosis is 
unfavorable, on account of the danger of a fatal termination from 
acute edema of the larynx and lungs. In the milder type the 
prognosis is unfavorable when the inflammatory process terminates 
in deep sloughing of the mucosa with its concomitant septic absorp- 
tion. 

In. the rhinitis due to mechanical causes the prognosis is good 
when the patient is withdrawn from the vicious environment or 
baneful occupation. 

Treatment. — The rhinitis of mechanical irritation is amenable 
to the same treatment as prescribed for an acute or chronic catar- 
rhal rhinitis. The treatment for the inflammatory reaction after 
operative manipulation is given on page 535. 

For the mild form of pharyngeal and laryngeal edema in the 
chemical variety, scarification, puncture and spraying with adrenalin 
solution 1 : 2000, or an aqueous cold-iced 50 per cent, ichthyol solu- 
tion have been found efficacious in reducing the waterlogged condi- 
tion of the connective-tissue spaces of the submucosa. Where 
asphyxia threatens, a tracheotomy becomes imperative. 



CHAPTER XXXIV. 
CHRONIC INFLAMMATORY AFFECTIONS OF THE NOSE. 



CHRONIC RHINITIS. 
SIMPLE CHRONIC RHINITIS. 

Synonyms. — Chronic coryza, chronic blennorrhea, rhinitis 
chronica, chronic nasal catarrh. 

Simple chronic rhinitis is a chronic inflammation of the nasal 
mucosa, accompanied by hyperemia, swelling and varying degrees 
of hyperplasia of the soft tissues, and changes in the secretions. 
The thickening of the mucous membrane varies according to the 
stage and severity of the disease. In the milder cases it is limited 
to a slight hyperplasia; but, when the disease is prolonged and of 
a severe type, the mucosa becomes the seat of turgescence, moderate 
hyperplasia and edematous infiltration. 

Etiology. — In simple chronic rhinitis the etiology differs only 
slightly from that of acute catarrhal rhinitis. In a general way the 
condition is attributed to long-continued factors of variable charac- 
ter, among which are the intranasal obstructions, impurities of the 
inspired air, or frequently recurring attacks of acute rhinitis, from 
which a perfect recovery has not taken place. The predispos- 
ing causes are also quite similar to those attending simple acute 
rhinitis. Diathesis plays an important role. Hence, gouty, rheu- 
matic, diabetic, and strumous patients are peculiarly liable. 

Pathology. — In simple chronic rhinitis there is at first an 
intense engorgement of the blood-vessels, both venous and arterial, 
which tend to lose their contractile power. Later there is marked 
relaxation of the tissues, with exudation of cell elements and the 
gradual increase in connective-tissue formation. Later on, contrac- 
tion takes place which may eventuate in glandular atrophy. This 
affection is probably due primarily to an invasion of pathogenic 
micro-organisms in a large proportion of cases, in proof of which 
may be cited the preponderance of patients in whom the disease 
dates from the exanthemata and other systemic affections. The 
bacillus of Friedlander, being found in all cases, is most likely the 
infectious agent, although the disease may be prolonged by sapro- 
phytic germs having their habitat in the nasal secretory .products, 
thus irritating the mucosa. 

Symptoms. — The chief clinical phenomena of simple chronic 
rhinitis are increased secretion and intranasal obstruction. The 
discharge during the earlier stages while profuse is of a watery 
character. As the condition becomes more chronic it becomes 
mucopurulent, with a tendency to the formation of crusts. Hawk- 
ing and spitting are complained of; the obstruction is usually more 
noticeable at flight and is liable to be attended with complete 

(501) 



502 NOSE AND NASAL ACCESSORY SINUSES. 

occlusion of one or both nostrils. The obstruction may alternate 
from one side to the other. The swelling of tin- mucosa is some- 
times influenced by gravitation, in which event the most dependent 
side during- sleep becomes obstructed, so that the patient by sleep- 
ing first upon one side and then upon the other is able to alternate 
his nasal breathing. 

Sufferers from simple chronic rhinitis are unduly prone to 
acute attacks. Along with the symptoms of simple rhinitis, dull 
pain over the bridge of the nose, frontal headache, and mental 
dullness (aprosexia) are complained of. The nasopharynx and 
larynx are often simultaneously involved, and the mucosa is often 
bathed with a mucopurulent exudate. Upon palpation the engorged 
tissues will be found extremely boggy and soft. Invasion of the 
Eustachian tube produces tubal obstruction and thereby causes 
attacks of acute catarrhal otitis media (see Chapter XVI t. 

Diagnosis. — The diagnosis of simple chronic rhinitis is not 
difficult to determine, except to differentiate between the simple 
and the hypertrophic forms. The diagnosis is founded upon the 
clinical history and the changes in the nasal mucosa, the latter 
being determinable by inspection, palpation and the character of 
the discharge. 

Prognosis. — The disease is aggravated to such a degree by 
environment, climate, and occupation that it is often a difficult 
matter to entirely eradicate it. The prognosis is favorably 
influenced by the adoption of measures which increase the resisting 
power of the individual (see page 494). This is accomplished by 
outdoor exercise, bathing (cold baths in the morning), the regula- 
tion of diet, and by the correction of individual habits which may 
be detrimental to one's efforts to relieve and cure. A cure, how- 
ever, is no guarantee against future attacks. In neglected cases the 
tissue changes gradually increase until well-marked hypertrophy 
becomes noticeable and the disease becomes a true hypertrophic 
rhinitis. 

Treatment. — Preliminary to local or operative interference the 
general physical condition of the patient should be carefully 
investigated. A history of rheumatism, gout, lithemia. diabetes, 
renal or hepatic lesions or syphilis necessitates proper internal, 
dietetic, and hygienic treatment. All reasonable means should be 
employed for developing the bodily resistance to acute attacks, in 
accordance with the suggestions outlined under preventive treat- 
ment of acute catarrhal rhinitis (Chapter XXXIII). While positive 
and permanent tissue changes may not he corrected by the above- 
mentioned measures, at least the further progress of the disease may 
be retarded. A very large percentage of cases of simple chronic 
rhinitis come under this general heading and are greatly relieved by 
constitutional and hygienic treatment. 

Septal spurs, deflections, and deviations (Chapter XXXV), 
when of sufficient size or of such shape as to interfere with respira- 
tion or drainage (Fig. 310), or when they remain in contact with 
the turbinated tissues (Fig. 362), should be considered as having a 



CHRONIC RHINITIS. 503 

causal relation to the disease and should be promptly removed. 
The same holds true with deformed, enlarged, or cystic turbinal 
bones (see Chapter XXXVI), although these are more prevalent in 
the hyperplastic form of the disease. All intranasal obstructions/ 
unless due to temporary hyperemia and congestion, should be 
removed by some form of operative interference. Usually the best 
results are obtained by combining needed surgical and constitu- 
tional treatment with frequent and thorough cleansing of the nasal 
cavities by means of bland saline solutions, and proper attention to 
hygiene and diet. 

Simple congestion and swelling of the tissues when unaccom- 
panied by hyperplastic changes do not require and should not be 
subjected to operative treatment. The temptation to cut or destroy 
the tissues at this stage is often very great. Occasionally, on 
account of the enormous and apparently uncontrollable swelling, it 
may be necessary to remove certain small portions in order to re- 
establish drainage and respiration. Under such circumstances the 
tissues should be removed surgically by means of clean cuts with 
knife or scissors (see page 551) ; never by caustics. Escharotics 
leave ugly sloughs, sometimes deeply seated, and accomplish but 
little permanent benefit. 

After-treatment. — Intranasal cleansing for a long period of 
time is often necessary, and, in damp or changeable climates, the 
majority of inhabitants have sufficient chronic rhinitis to require at 
least morning cleansing of the nasal cavities. 



CHRONIC HYPERPLASTIC (HYPERTROPHIC) RHINITIS. 

Synonyms. — Chronic hypertrophic rhinitis, hypertrophy of the 
turbinated bones, hypertrophic nasal catarrh. 

In the hypertrophic or hyperplastic form, chronic rhinitis is an 
inflammatory process which involves the nasal mucosa, more espe- 
cially the turbinal tissues, and is accompanied by permanent increase 
in the soft tissues and changes in the character of the secretions. 

Etiology. — The hypertrophic form of chronic rhinitis is always 
a result df prolonged or neglected simple chronic rhinitis. The 
inflammation which accompanies recurrent attacks of the acute and 
prolonged simple chronic rhinitis must inevitably lead to sufficient 
tissue increase to produce true hyperplasia. Deformities, enlarge- 
ments of the turbinated bones (see Chapter XXXVI), septal spurs 
and deflections (see Chapter XXXV), by causing pressure upon the 
surrounding tissues and interfering with drainage and respiration, 
become common etiological factors. Defects in nasal conformation 
whereby the nostrils do not sufficiently dilate to admit of proper 
nasal respiration are frequently overlooked etiologically. The affec- 
tion is extremely liable to occur in patients who suffer from such 
constitutional diseases as rheumatism, gout, diabetes, and anemia, 
and it is influenced by climate, occupation, diet, and habits of fixing. 
Advanced chronic and hyperplastic rhinitis is rarely observed under 
adult age, and men seem to be more susceptible to it than women. 



504 NOSE AND NASAL ACCESSORY SINUSES. 

Pathology. — During the early stages the turgescence may 
largely be accounted for by a general and almost continuous dila- 
tation of the blood-vessels, but the dilatation gradually becomes 
complicated by connective-tissue infiltration and gradual increase in 
the thickness and density of the soft tissues. As the disease pro- 
gresses, the walls of the blood-vessels also become thickened and 
infiltrated, the tissue increase receiving its blood-supply from newly 
developed capillaries. The hyperplasia is chiefly located in the 
tissues covering the inferior turbinal bone, the posterior end of 
which frequently becomes enormously enlarged (Fig. 355), its outer 
surface uneven, sometimes with deep lobulations and indentations. 
Smooth, circumscribed excrescences have been designated as poly- 
poid hypertrophies or degenerations and hyperplasias ; those with 
very uneven surfaces as papillomata (Hofmann) ; but these designa- 
tions are objectionable from an histological point of view. 

Symptoms. — The chief clinical phenomena are nasal obstruc- 
tion, greatly altered secretions, and in many instances slight odor. 
The degree of nasal obstruction depends upon the severity of the 
disease and the location of the swelling, and it varies from partial 
permeability to total closure of the nasal chambers. None of these 
symptoms should be considered absolutely pathognomonic, inas- 
much as they are also observed in simple chronic rhinitis and in 
those individuals who suffer from nasal deformities which produce 
obstruction. In the chronic form, however, the symptoms men- 
tioned are almost constantly present, although varying in degree. 
The mucosa of the affected parts is thickened, congested, and often 
bathed with a mucopurulent exudate. Hyperplasia, even to a slight 
degree in narrow nostrils, is sufficient to give rise to marked 
evidence of nasal obstruction. In youthful individuals true hyper- 
plasia rarely is found, the simple chronic catarrhal form being more 
prevalent before puberty. During the earlier stages the mucous 
membrane usually is much reddened, but, when the hyperplasia is 
excessive, and shows a tendency to polypoid appearance, with 
uneven or lobulated surfaces, the membrane often becomes pale 
and usually is covered with a mucopurulent secretion. Enlarge- 
ment of the turbinal bone itself is occasionally observed, but is not 
the rule. Variations in shape, particularly of the inferior turbinals, 
are often mistaken for enlargement. As a rule, deformities of the 
septum are present, with ridges or spurs, which impinge upon the 
soft tissues and thus aggravate the symptoms. In nervous or sen- 
sitive individuals the nasal obstruction constitutes an extremely 
annoying symptom, especially at night, at which time the obstruc- 
tion alternates from side to side, by gravitating toward the side 
which is next to the pillow. Mouth-breathing, especially at 
night, becomes the rule, and it is often accompanied by snoring. 
An annoying symptom resulting from mouth-breathing is the 
extreme dryness of the mouth and throat. In advanced cases of 
long standing there is diminution or loss of the sense of smell 
(anosmia). 



CHRONIC RHINITIS. 505 

Nasal obstruction, long continued, results secondarily in 
marked interference with the mucous membrane of the postnasal 
and pharyngeal regions, Avhereby it gradually becomes congested 
and inflamed. 

Occasionally nasal polypi will be found, although as a rule 
these tumors are directly caused by chronic infection of the acces- 
sory sinuses and commonly protrude from their orifices. The 
obstructive lesion within the nasal chambers usually interferes with 
the resonance (timbre) of the voice. The obstruction as a rule 
arises from the inferior turbinal, and the soft tissues in its imme- 
diate vicinity often become much hypertrophied. Occasionally 
aprosexia ensues on account of the long-continued intranasal pres- 
sure, and headache is a common symptom. The secretion is always 
altered in proportion to the extent of the inflammatory changes 
which have taken place in the soft tissues. The secretion shows a 
tendency to become viscid and thick, and clings to the surfaces with 
considerable tenacity, sometimes becoming incrusted, in which 
event its removal is difficult. Infection of the retained secretions 
with saprophytic bacteria results in fermentation and an offensive 
odor, a condition which undoubtedly produces much local irritation 
of the mucosa. 

Of the more remote symptoms the following are noteworthy, 
viz., cough, due to the presence of the secretion in the nasopharynx; 
hawking and clearing of the throat ; sneezing evoked by contact pres- 
sure of opposing membranes ; sensations of pressure about the eyes 
and forehead ; surface ulcerations upon the septum and mucous mem- 
branes; excoriations and redness about the nasal orifices, and, finally, 
tinnitus and a sensation of fullness in the ears. 

Diagnosis. — An exhaustive examination of the entire nasal and 
nasopharyngeal tract is essential in order to render a positive diag- 
nosis, and it should be conducted in the following manner : After 
ascertaining a history of the case from the patient, he should be 
subjected to a thorough examination of the nasal passages, begin- 
ning with an anterior rhinoscopic examination, meanwhile care- 
fully noting the color of the membrane, the degree of its apparent 
thickening, the location of such thickening, the general form of the 
turbinals, the presence or absence of septal deflections and spurs, 
and the amount and nature of the secretions. This should be fol- 
lowed by posterior rhinoscopy, thereby observing the general ap- 
pearance of the mucosa of the rhinopharynx, whether adenoids or 
adhesive bands are present, the conditions of the posterior ends of 
the turbinals, and the patulency of the orifices of the Eustachian 
tubes. The nature of the postnasal secretions likewise should be 
determined. Knowing that the intumescence accompanying acute 
eoryza,and simple chronic catarrh, and that the engorgement re- 
sulting from plethora, local irritants or neuroses, are accompanied 
with apparent true hyperplasia, means of differentiation should be 
employed. This is best accomplished by Spraying the entire mucous 
surface with a weak solution of cocaine. This application is imme- 



506 NOSE AND NASAL ACCESSORY SINUSES. 

diately followed by rapid reduction of the engorgement which 
attends the simpler forms of congestion, and even in that associated 
with a simple chronic catarrh. True hyperplasia, however, still 
will remain, but the superficial engorgement will be reduced, even in 
hyperplastic conditions. The employment of suprarenal solution is 
less efficacious for diagnostic purposes, inasmuch as the effects of 
the remedy are too drastic and the contraction of the blood-vessels 
is too extensive. 

Examination subsequent to the cocaine shrinkage will, if true 
hyperplasia be present, reveal the following conditions, depending 
upon the stage and extent of the pathological process. Examina- 
tion with the probe, with slight pressure upon any portion of the 
hyperplastic areas, will reveal a boggy condition, upon which, if 
indentations are made, the impression fills in rather slowly, the 
contrary being true when the enlargement is due to turgescence of 
the mucosa. The rapid resumption from the indentations indicates 
an early stage of the disease, or that the affection is nut true hyper- 
plasia. The chronicity of the hyperplastic development is propor- 
tionate with the length of time observed in the filling in of indenta- 
tions. 

In some cases the under surface of the inferior turbinal is found 
to rest upon the meatal floor after cocainization, and retained secre- 
tions are located along the lateral nasal wall. The hyperplasias 
often amount to mulberry-like tumors, which surround the posterior 
ends of the inferior turbinals (Fig. 354). Usually these are nodular, 
but occasionally the surfaces are smooth and glistening. In 
extreme cases the same mulberry-like pendulous membranous 
enlargement may extend along the entire under surface of the 
inferior turbinal, and protrude into the epipharynx, where they are 
commonly mistaken for polypi. Extensive hyperplasia of the 
tissues covering the middle turbinal, unaccompanied by complicat- 
ing sinus infection, is rare. 

A membranous thickening upon one or both sides of the nasal 
septum, usually more marked in the upper portion or along the 
attachment of the vomer and cartilaginous portions,' occasionally 
occurs. Such thickenings to a mild degree are usually present. 

Idle peculiar pale, rounded mass will be observed along the 
posterior border of the vomer, just inside the choanal and is seen 
only by posterior rhinoscopy. These are prone to occur when 
deflections or spurs are present, although occasionally they are 
bilateral. 

( >ne or more of the above-described conditions may be present 
in the same patient. While chronic hyperplastic rhinitis rarely is 
unilateral, often there is marked-variation in the two sides. When 
associated with septal deflections or spurs the disease may be limited 
to the side upon which such spurs or deflections exist. 

Differential Diagnosis.— The application of cocaine spray elimr- 
nates the more acute swelling which accompanies acute corvza, 
simple chronic catarrh and the various neuroses. At the same time 



CHRONIC RHINITIS. 507 

it brings into view deflections, spurs, polypi, and foreign bodies. 
The tumors, whether malignant or benign, such as fibromata, polypi 
and malignant growths, usually are circumscribed, while hyper- 
plastic swellings cover larger segments of the mucosa. Hyperplasia 
gives an air-cushion sensation upon contact with the probe ; whereas 
fibromata admit of considerable motion and are denser. 

Malignant growths are localized, dense, and accompanied with 
glandular enlargement and other characteristic symptoms (see 
Chapter XLII). 

Prognosis. — Under proper hygienic surroundings, when unac- 
companied by grave general disease, in patients who submit to the 
proper local and surgical treatment the prognosis is favorable. The 
chief difficulties are those resulting from habits of life, occupation, 
general environment and systemic diseases. 

Treatment. — Medicinal treatment, whether applied locally or 
administered internally > is palliative and of some benefit, neverthe- 
less it is inadequate on account of the presence of the inflammatory 
new formations ; hence operative procedures of some form must be 
relied upon for permanent relief. Extensive operations, however, 
rarely are necessary, except in advanced cases where more or less 
obstruction has taken place. It is important that the mucous 
surfaces be kept clean as possible and all retained secretions 
removed. For this purpose bland, non-irritating alkaline sprays 
are most efficacious. 

After cleansing, the surfaces should be sprayed with a medi- 
cated oily preparation (Douglas formula of benzoinol, page 496) 
both for the purpose of protecting the freshly cleansed membrane 
from the deleterious influences of dust or even exposure to cold air, 
and to obtain the benefit of the local application of the medicaments. 
The majority of the spray solutions in general use are too strong 
and induce a marked irritating effect upon the nasal mucosa, which 
results in a prolonged watery secretion from the nose. Sprays con- 
taining glycerin produce like effects. Postoperative spraying is 
also essential in order to remove excessive secretions and to main- 
tain at least partially aseptic surfaces. 

Rheumatism, gout, diabetes and that form of malnutrition in 
which an excess of uric acid is present require prompt and thor- 
ough internal administration of proper remedial agents. When 
accompanied by disturbances of digestion and assimilation marked 
amelioration of the intranasal symptoms will be obtained by the 
administration of cathartics and other remedies which tend to 
restore these functions. Patients of plethoric habit, the gouty, the 
alcoholic or dyspeptic types should submit to regulation of diet, 
abstain from excesses of alcohol and tobacco, take sufficient exer- 
cise and avoid overheated rooms. A sojourn at some healthful 
resort, especiallv where a simple regime with baths, etc, is enforced, 
is mosl beneficial. For patients of the thin, neurotic type, Parker 
recommends the following mixture to be taken three times a day :— 



508 NOSE AND NASAL ACCESSORY SINUSES. 

R Citrate of iron and ammonium gr. x. 

Carbonate of ammonium . . : gr. v. 

Fowler's solution Riij. 

Tr. nux vomica ntv. 

Glycerin nixv. 

Water q. s. ad oj. 

The suggestions made under the preventive treatment of simple 
acute rhinitis, page 49-1, should be adopted. 

The operative treatment of hypertrophic rhinitis is described 
in Chapters XXXV and XXXVI. 

ATROPHIC RHINITIS AND OZENA. 

Atrophic rhinitis, chronic atrophic rhinitis, cirrhotic rhinitis, 
rhinitis sicca and rhinitis atrophica are the synonyms applied to an 
atrophic state of the nasal mucosa and turbinal structures, resulting 
from one of several inflammatory processes. Marked variations in 
character, extent, and symptoms are observed during a careful study 
of a series of cases of atrophic rhinitis. 

In some individuals the mucous membrane only is involved, 
and occasionally one cavity only, while in others there is a marked 
tendency to absorption of the bony structures within the nose and 
the accumulation of masses of malodorous inspissated crusts. The 
simple form may not be attended with distinctive symptoms, but 
the secretions are always altered as a result of the pathological 
changes. 

Etiology. — The actual cause of atrophic rhinitis never has been 
definitely demonstrated, although much speculation has been 
indulged in by careful observers whose conclusions have shown 
wide variance. The author's observations, based largely upon 
clinical experience, have convinced him that the condition results 
from a considerable number of etiological factors acting either alone 
or in combination. That an inflammatory process of long duration, 
or one which has rapidly involved the nasal mucosa, and which 
furthermore has seriously interfered with the blood-vessels of these 
parts and consequently with the nutrition of the tissues, thereby 
inducing hyperplasia, should finally result in such further altera- 
tions in nutrition as to produce serious structural degeneration, 
resulting in atrophy, does not seem improbable. Clinically this 
undoubtedly occurs, but why this result should be found in one 
case and true hypertrophy of both mucosa and bone in another, 
which, never terminates in atrophy, it is difficult to understand. 
That atrophy often occurs without a preceding hypertrophy may be 
easily demonstrated, proving definitely that the atrophic state is 
not necessarily to be considered as a later stage of an hypertrophic 
inflammatory process. While opinions vary as to the primary or 
secondary nature of atrophic rhinitis the preponderance of evidence 
favors the view that it is always secondary to some pre-existing 
local inflammation. Syphilis should not be considered as having 
any causal relation, although occasionally a specific history accom- 



CHRONIC RHINITIS. 509 

parries the disease, as do tuberculous and other grave systemic 
affections. Micro-organisms, accessory-sinus disease; glandular 
degenerative processes, individual idiosyncrasy and diathesis may 
play a part, but are not specific etiological factors. 

In its simplest form it may not be a degenerative process, inas- 
much as the cellular tissue having become so impaired and reduced 
as a result of diminished nutrition may produce what must be 
termed simple atrophy, a condition which readily improves as soon 
as its cause is removed. In this form the contraction observed 
follows a pre-existing inflammation which has lessened the vascular 
supply to the part. 

Another simple variety, usually local and unilateral, results 
from the pressure of septal deflections or spurs. 

It is doubtful whether atrophic rhinitis per sc is an inflamma- 
tory condition. Simple atrophy, however, should not be confounded 
with the more chronic form wherein a true degeneration has taken 
place. 

Abnormally wide nasal cavities in rather flat noses seem to 
furnish a large proportion of intranasal atrophy. A hereditary 
tendency to this affection is often discovered. Traumatism, infec- 
tious diseases, especially membranous rhinitis, and the pernicious 
results of inhalations of poisonous fumes and prolonged subjection 
to insufficient nourishment and badly ventilated living rooms, are 
important etiological factors. The condition rarely begins after 
the twenty-fifth year. The larger proportion of cases manifests a 
tendency to the disease in early life, at about the twelfth year, excep- 
tionally earlier — and it is more common in females than in males. 
It almost invariably is accompanied by anemia. 

Pathology. — In the severer forms the following pathological 
alterations in the mucosa are to be observed : The normal epithe- 
lium gradually desquamates, and the surface of the membrane 
assumes a smooth, pale, unnatural appearance. Changes in the 
submucosa result in a marked decrease in the connective tissue. 
With this is associated a gradual obliteration of the glandular 
structures, and a marked tendency to obliteration of the blood- 
vessels. As the contraction progresses, the structures become more 
or less nitrous, and finally the turbinal bones atrophy. The lower 
turbinals diminish in size or disappear entirely, while the middle 
turbinate usually remain in part, even in the severe cases. Bacteria 
of many varieties are invariably found, but so far no typical path- 
ological organism has been isolated. 

Symptoms.— The prominent symptom noted in this disease is 
the marked alteration in the character of the secretion. Visual 
examination reveals wide-open nostrils, with a more or less com- 
plete loss of the normal anatomical landmarks, and a marked 
change in the color and general appearance of the mucosa. The 
mucous membrane frequently is obscured by greenish colored, 
inspissated masses, underneath which arc areas of ulceration. 
Associated with the dark crusts there is usually an accumulation 
of purulent or mucopurulent secretion, occupying the more depend- 



510 NOSE AXD XASAL ACCESSORY SINUSES. 

ent portions of the nares, and commonly purulent secretion is seen in 
the ethmoid region. Unless the nasal cavities have been recently 
cleansed they are partially or wholly tilled with masses of inspissated 
secretion, and when ozena is present marked fetor will be noted. The 
odor is not unlike that which accompanies bone necrosis. It is ex- 
tremely fetid and probably because of the decomposition which has 
taken place in the mucopurulent discharge. Some authors believe 
is a special ferment in these secretions, an opinion that is not 
without reason, inasmuch as an ordinary purulent rhinitis, with appar- 
ently the same character of secretion, may go on almost indefinitely 
emitting an ordinary catarrhal odor only. Victims of this affection 
rarely are conscious of the distressing odor, inasmuch as the, terminal 
filaments of the olfactory nerve have been involved in the atrophic 
process. 

Ozena. — The term ozena, derived from the Greek oiaiva, mean- 
ing a fetid polypus in the nose, designates a peculiar diffuse dis- 
of the nasal mucosa, which is characterized by the production 
of a thick, specific, highly offensive secretion, with a tendency to the 
formation of flakes and crusts, and attended by atrophy of the mucosa, 
together with certain portions of the subjacent framework of the 
interior of the nose (Zarniko). The early writers undoubtedly made 
use of the term to cover all intranasal diseases attended with odor, 
whether syphilitic or simple ozena. Later on its use became more 
restricted, and it was employed to designate catarrhal conditions which 
are characterized by the decomposition of retained intranasal secre- 
tions, hut it was still looked upon as a disease rather than a symptom. 
According to our present understanding, the term practically stands 
for an affection which has been described under Zarniko's definition. 
It hecomes necessary, however, to differentiate various other diseases, 
which may be accompanied by offensive odor, as, for example, syph- 
ilitic necrosis, certain accessory-sinus diseases, glanders, and some 
neoplasms. 

At the I'd 7 meeting of the American Laryngological Association, 
Dr. Lewis A. Coffin in presenting a series of X-ray pictures, showing 
diseased sinuses in children, remarked that "the condition shown, unless 
spontaneously recovering, is the forerunner of a future atrophic rhin- 
itis." ITe drew attention to the following points : 1, the frequency with 
which the antrum had shown disease; 2, that the antrum when dis- 
eased is often most foul as to odor — a condition obtaining in no other 
sinus; 3. that many eases of ozena in his hands had cleared entirely as 
to odor from opening, ventilating and washing the antrum through 
the inferior meatus; 4, that, in fact, only one of about twelve, so 
treated, had failed to clear up as to odor; and 5, that he attributed this 
failure to the fact that the odor of ozena is due to the stagnating and 
putrefying processes that take place in a chronically diseased antrum. 

Losworth 1 probably is correct in his deduction that in atrophic 
rhinitis there is marked decrease in the quantity of nasal secretion, 
and that the apparent discharge in atrophic rhinitis is partially due 



Diseases of the Nose and Throat, p. 169. 



CHRONIC RHINITIS. 511 

to the fact that, on account of the long pre-existing inflammatory 
process, the normal serous exosmosis has subsided. 

The presence of large masses of secretion gives rise to symptoms 
of obstruction which entirely subsides after their removal, and, while, 
with wide-open notrils, clear of discharge, the intake of air is usually 
free, the dryness of the membranes often extends to the nasopharynx 
and larynx, where it induces annoying irritation. Superficial ulcera- 
tion, although rare, sometimes occurs, especially along the cartilagin- 
ous portion of the septum, and is due to constant picking of the nose 
in an effort to remove the crusts. These ulcerations occasionally go 
on to perforation of the septum. The crust masses usually remain in 
situ for several days, finally being forced out of place and dislodged 
in whole or in part as the result of the effort of the patient to obtain 
relief from the annoying obstruction. Unless aided by sprays' or 
douches the cavities rarely ever become thoroughly clean and free 
from crusts. Epistaxis occasionally follows the efforts to dislodge the 
retained secretion, especially if vigorous mechanical means are em- 
ployed. The dryness of the pharynx and larynx probably results from 
the loss of normal moisture imparted to the air in its course through 
the nasal cavities. In severe cases masses of dried, inspissated mucus 
form in the epipharynx, thereby causing a sensation of irritation which 
necessitates vigorous efforts for' removal. A common complication in 
advanced cases is a tendency to a deposit of crusts upon the walls of 
the pharynx, larynx, and trachea in consequence of the lack of mois- 
ture which is normally imparted to the air while passing through the 
nasal cavities 

Differential Diagnosis. — It is necessary to differentiate ozena as 
a symptom from chronic sinusitis other than the antrum. Syphilitic 
and" tuberculous lesions, especially when there has been marked 
destruction of tissue, resulting from necrosis of both the soft and 
bony intranasal structures, may be confounded with atrophia rhinitis. 
Syphilis with necrosis produces an odor quite similar to ozena. Ac- 
quired syphilis, however, rarely occurs in extreme youth, and even 
when suspected a clear history usually can be elicited. The odor 
which accompanies prolonged retention of foreign bodies in the nasal 
cavities may lie confounded with ozena, but a rhinoscopic examina- 
tion, aided by the probe, usually reveals the foreign body if present. 

Prognosis. — Tn this disease the mucous membrane has well-nigh 
lost its normal secreting function, and its glandular structures have 
largely become obliterated. Marked changes both in the mucosa and 
the submucosa also have occurred ; the turbinals have become reduced 
and their erectile function destroyed. With these known and incurable 
conditions the prognosis is unfavorable so far as complete restoration 
(ff normal function is concerned. Even to modify the discharge and 
control the symptoms require frequent and indefinitely continued treat- 
ment. During the earlier stages in the class of case- where the appar- 
ent atrophy has resulted from some pre-exist cut local lesions, such as 
deformities of the septum, septal spurs, etc., or from empyema of the 
accessory sinuses, it is quite possible to arresl the disease and often to 
restore the functions of the nasal mucosa. The same applies to treat- 



512 



NOSE AND NASAL ACCESSORY SINUSES. 



merit inaugurated early in the history of the disease, and antedating 
the period when fetid symptoms appear. Fortunately after middle life 
the disease tends to become less annoying, with less tendency to the 
formation of crusts and hence less fetor. 

Treatment. — Local treatment should be antedated by a careful 
physical examination of the patient and a minute inquiry pertain- 
ing to the general history. The varieties and severity of the dis- 
eases from which the individual has suffered, and any grave 
constitutional disease or hereditary tendency, should be given full con- 
sideration. As a rule these patients require well-directed internal 
medication in the form of iron, cod-liver oil, potassium iodid and the 
hypophosphites, and full instructions relating to hygiene, diet, and 
habits of life. 

The primary indication in the local treatment of the disease 

is the softening and removal of 
the secretions and thorough 
cleansing of the nasal mucosa. 
Two general varieties of medi- 
caments are appropriate for 
»/// this purpose : first, those em- 
s===f ^ sS **' !/// ployed for softening and re- 
ty ;/// moving the incrustations and 

secretions ; second, those em- 
ployed for deodorizing the sur- 
il^^fes^-rrf s^ps faces and stimulating the mu- 

cosa. The ordinary intranasal 
spray apparatus is of little 
avail, inasmuch as an insuffi- 
cient quantity of fluid can be 
sprayed. A fountain syringe or some form of douche-cup (Fig. 304) 
or postnasal syringe (Fig. 305) are requisite, in order to separate the 
crusts, and bland aqueous solutions should be employed. A powder 
made up of sodium bicarbonate and sodium chlorid in the proportion 
of two to one, kept dry, of which a teaspoonful may be used in a pint 
of warm water for syringing or douching, will suffice, although other 
alkaline solutions may be used. Whenever the masses are unusually 
dry and tenacious the cleaning process will be facilitated by employing 
a warm solution (1 to 3 dilution) of peroxid of hydrogen to be fol- 
lowed by the blander solutions heretofore mentioned. Kyle recom- 
mends the following mixture for cleansing the mucous surfaces : — 

R Sodii biboratis, 

Sodii bicarbonatis, 

Sodii chloratis, 

Potassii bicarbonatis aa gr. xv. 

Acidi carbolici rn_ ii j. 

Aquae destillatre q. s. ad 5i j. 

M. Sig. : To be used with nasal douche. 

Patients should be instructed how to properly employ the 
douche and thus avoid its dangers. The Fowler nasal douche (Fig. 




CHRONIC RHINITIS. 513 

304) obviates the dangers in part. Any ordinary douche-bag or 
receptacle, having been filled with the solution, should be hung at 
a point just a little above the level of the nose, with the tip intro- 
duced into one nostril; the patient in the meantime should breathe 
through the wide-open mouth, with the head bent slightly forward. 
This will close off the nasopharynx from the oropharynx, and the 
water flowing into one nostril will return from the other. Too much 
force should not be used, and it is imperative that the patient should 
be cautioned not to blow the nose in the ordinary way — by closing 
one nostril — but to blow both nostrils simultaneously without finger 
pressure and in this way dislodge the crusts. These precautions are 
necessary in order to prevent the introduction of infection into the 
middle ear. Middle-ear infection occasionally occurs from the 
injudicious use of the nasal douche, but, if the precautions hereto- 
fore mentioned are followed, this unfortunate accident will not 
occur. While, as a rule, patients should be advised against the use 
of the nasal douche for ordinary catarrhal conditions, in atrophic 
rhinitis with ozena its employment is justifiable. After a few 
minutes the larger masses will loosen and come away. It is impor- 




Fig. 305.— Postnasal syringe. 

tant, however, that every particle of retained secretion should be 
removed at each treatment, by means of cotton probe or forceps. 
The author has found that dipping the cotton-tipped probe into 
rather hot water aids materially in wiping away the remaining 
secretion. 

The postnasal region should also be inspected and completely 
cleansed. For this purpose it is sometimes necessary to use a small 
throat mirror while wiping away the crusts with a curved appli- 
cator. The author's flexible silver applicator (Fig. 432) serves well 
for this purpose. After thorough cleansing, the entire mucosa 
should be subjected to an application of some form of stimulating 
and disinfecting solution. For this purpose ichthyol heads the list. 
The following formula is recommended : — 

$ Ichthyol, 

Glycerin aa 3ij. 

Aquns q. s. ad Sj. 

This should be wiped over the entire surface by means of 
cotton-tipped applicators. More recent experience with argyrol in 
25 per cent, solution has also shown favorable results. Variations 
in the remedies used are desirable, both in the cleansing and the 
stimulating applications. The Mandel solutions, in the following 
formula;, are also highly commended by various authors, for apply- 
ing to the nasal membranes after the secretions have been removed. 

33 



514 NOSE AND NASAL ACCESSORY SINUSES. 

Mandel No. 1. 

ft Glycerin 3v. 

Potassium iodid 3ij. 

Iodin 3ss. 

Mandel No. 2. 

ft Glycerin 3v. 

Potassium iodid 3iv. 

Iodin 3j. 

Mandel No. 3. 

ft Glycerin 3v. 

Potassium iodid 3vj. 

Iodin 3iss. 

The acetotartrate of aluminum in the proportion of from ^ to 
1 dram to the ounce has both a stimulating and antiseptic effect 
upon the membranes. 

Packing the nose with cotton lint or gauze, thereby causing a 
watery secretion, is a painful procedure and would be available for 
the nasal cavities only, and is of doubtful efficiency. 

The above treatment does not contemplate the restoration of 
the altered mucosa. Its real purpose is to rid the patient of the 
disgusting stench and discomfort of the retained secretions, and 
possibly to arrest the further progress of the disease. Patients 
usually seek relief from the ozena, and they should receive the 
encouraging advice that by persistent and long-continued treat- 
ment, aided by intelligent and carefully directed home treatment, the 
distressing symptoms at least may be controlled. They should 
frankly be told that in order to accomplish this the treatment 
must be painstaking and long continued. They should be taught 
how properly to use the douche and to make local applications to 
-the nasal mucous membrane, and even to that of the nasopharynx. 
It is quite possible to train these patients to use even the postnasal 
syringe with safety. Two or three daily home treatments and 
several office treatments each week for a period of several months 
will be necessary. Home treatment night and morning at least will 
be found necessary for an almost indefinite period of time. It is 
often difficult to persuade patients to persist in carrying out the 
twice-daily intranasal cleansing after they become comparatively 
free from the formation of crusts. 

Vibratory massage of the nasal mucosa is a painful procedure. 
Mechanically it gives rise to considerable watery secretion, but its 
results are nil. The same holds true with the galvanic current. 
The galvanocautery is contraindicated, inasmuch as in this disease 
it is reprehensible to destroy any tissue within the nose, except 
unhealthy granulations or polypi. Ulcerating surfaces should be 
cleansed and touched with a solution of nitrate of silver, 30 to 60 
grains to the ounce. 

A. Blau has recommended the use of paraffin to build up 
atrophied turbinal bones in order to secure normal circulation of 



CHRONIC RHINITIS. . 515 

the air current in the nares. The operation consists in an attempt 
to reconstruct the form of the inferior turbinal tissues by means of 
injections of semisolid paraffin into the submucous tissues. It is 
claimed that the following results are obtained : 1, the secretion 
becomes thinner; 2, the tendency to the formation of crusts is 
lessened, and, 3, a larger surface of mucous membrane is gained, 
and thereby more moisture is imparted to the inspired air. 

Lake recommends that the injections be small, with repetitions 
at intervals of about one week. The method requires a needle three 
inches in length, which is attached to the paraffin syringe (Fig. 
414). In three cases reported by Broeckart there were decided 
changes in the secretion, and the crust formations diminished. The 
technique of paraffin injections is described in Chapter XL. The 
lactic acid bacillus in pure culture has been recommended for the 
local treatment of this affection. From 15 to 20 minims of the 
solution should be dropped into the nostril, the head being thrown 
backward in order that the solution may flow over the nasal mucosa. 

The high-frequency current also has been advocated as a 
measure of local treatment. The current should be applied directly 
to the diseased mucosa by means of small, especially devised appli- 
cators. 

CHRONIC PURULENT RHINITIS. 

Synonyms. — Suppurative rhinitis, purulent nasal catarrh. 

Definition. — Chronic purulent inflammation of the nasal 
mucosa, unaccompanied by purulent sinusitis, is a rare affection. 
It is characterized by a persistent purulent rhinorrhea, due to infec- 
tion of the nasal mucous membranes, and usually dates from child- 
hood. 

Bosworth contends that it occurs as a primary affection in 
children and eventuates in atrophic rhinitis in adult life. It should 
be differentiated from the far more common purulent sinusitis. 

Etiology. — It is believed to be primarily due to some acute 
infectious disease like the exanthemata, and to be aggravated by 
attacks of simple acute rhinitis. 

It is probable that in a considerable proportion of the cases the 
primary infection occurs at birth from infected vaginal secretions 
from the mother. Kyle describes two cases in adults in which the 
infection was carried to the nasal mucosa, one from the urethra 
and the other from a discharging ear, by means of the patient's 
finger. 

Purulent rhinitis rarely is seen by the rhinologist during the 
incipient stage. There is a profuse discharge of an admixture of 
pus and mucus in varying proportions. The mucous membrane 
becomes the seat of marked hyperemia, but without bogginess or 
hyperplasia. 

Symptoms. — The predominating symptom is a persistent dis- 
charge from both nostrils of a yellowish, viscid, mucopurulent fluid. 
While the rhinorrhea is not fetid, it often is so profuse that the 
nasal cavities become blocked and the excess flows backward into 



516 NOSE AND NASAL ACCESSORY SINUSES. 

the pharynx and forward over the surface of the upper lip. Tempo- 
rary relief from the obstructive symptoms is obtained by blowing 
or washing out the retained secretion. 

Diagnosis. — The diagnosis is based upon a painstaking ex- 
amination of the anterior nasal cavities in order to exclude purulent 
sinusitis, foreign bodies and tuberculous and syphilitic affections as 
a cause of the rhinorrhea. 

Prognosis. — Without treatment the disease tends to progress, 
and there is considerable ground for the belief that it may eventuate 
in chronic atrophic rhinitis with ozena. Cases which during the 
early stage are placed under proper treatment usually recover, 
but any changes which have taken place in the structure of the 
mucous membrane will remain permanent. 

Treatment. — The prophylactic treatment heretofore described 
for simple catarrhal rhinitis should be inaugurated at once (Chapter 
XXXIII), in order to build up the resisting power of the patient 
and to lessen the tendency to exacerbations. If any underlying con- 
stitutional affection is discovered, it should be subjected to proper 
internal treatment, to which iron, cod-liver oil, or arsenic may be 
added with benefit. 

Locally, the treatment should consist in keeping the nasal 
mucosa as clear and as free from retention of pus as possible. In 
children the nasal douche employed two or three times daily, pre- 
cisely the same as for scarlet fever and diphtheria (Fig. 290), is 
most effective for cleansing purposes. Meanwhile, all the pre- 
cautions heretofore mentioned under the treatment of atrophic 
rhinitis should be observed, in order to preserve the middle ear from 
infection. 

As a preliminary measure, and for the purpose of actively 
attacking the pus secretion, the nose may be sprayed once a day 
with a dilute solution of hydrogen peroxid (Kyle), to be followed 
by a douche of normal physiological salt solution, or a saturated 
solution of boric acid, or the following : — 

B Sodii bicarb., 

Sodii biborat aa 3ss. 

Borolyptol 3iv. 

White sugar 3ij. 

Aquae q. s. ad Sviij. 

Solutions of hydrarg. bichlorid, while unavailable for young 
children, may be employed in older persons, but in the nose the 
strength of the solution should not exceed 1 : 8000, or 1 : 10,000. 

Following the cleansing process the membrane should be wiped 
dry with a cotton-tipped applicator, after which an astringent should 
be applied. The astringent may be applied in the form of a spray 
or by means of cotton carriers. Nitrate of silver solution, from 10 
to 30 grains to the ounce, or solution of argyrol, 25 per cent., may 
be applied over the entire diseased surface. 

Bosworth recommends a formula as follows : — 



CHRONIC RHINITIS. 517 

I£ Sulphocarbolate of zinc gr. xl. 

Bichlorid of mercury gr. %. 

Aquse q. s. ad Sviij. 

M. Sig. : Apply to the mucous surfaces after cleansing. 

By carefully and persistently carrying out the treatment out- 
lined above, in the majority of cases a successful outcome may be 
expected. It is often necessary to prolong the treatment for several 
months in order to succeed. 



RHINITIS FROM SPECIFIC INFLAMMATIONS 
(Diphtheria, Scarlatina, Measles, Grippe, etc.). 

See Chapters XXIX, XXX, XXXI, and XXXII, on the Influ- 
ence of General Medical Diseases upon the Ear, Nose, and Throat. 

k 

RHINITIS CASEOSA. 

This rare affection receives its name from its chief symptom, 
which is a persistent exudation of fetid, cheesy secretion into the 
nasal chambers. 

Etiology. — While its cause is not definitely known, it is 
believed to result from some grave constitutional disease like tuber- 
culosis or syphilis, associated with chronic rhinitis. 

Pathology. — There is no distinctive pathological lesion; neither 
is there any definite micro-organism in the discharge. 

According to Kyle, the caseous exudate contains microscopi- 
cally granular leucocytes, fatty cells, cholesterin crystals and 
stearin. 

Symptoms. — The chief symptoms are loss of the sense of 
smell, considerable headache, nasal obstruction, and discharge of 
extremely fetid odor. 

Treatment. — 1. Thorough cleansing and scraping away of the 
accumulated material, aided by sprays of dilute peroxid of hydro- 
gen, or boric acid solution. 

2. A thorough examination of the intranasal structures and 
accessory sinuses, in order to ascertain whether they are the seat 
of specific lesions. 

3. Destruction of granulations, removal of necrosed bone when 
found. 

4. The application of solutions of silver nitrate 10 to 30 grains 
to the ounce; or argyrol, 25 per cent., to the mucosa. 



CHAPTER XXXV. 
THE NASAL SEPTUM AND ITS PATHOLOGICAL CONDITIONS. 



ANATOMY. 

Three individual structures enter into the formation of the 
nasal septum. The lower posterior portion is formed by the vomer, 
the upper posterior by the perpendicular plate of the ethmoid, and 
the remaining or anterior portion by the triangular cartilage (Fig. 
306), the latter being the portion chiefly involved in septal deformi- 
ties. The entire framework consists of the vomer, the perpen- 
dicular plate of the ethmoid, the palatine crests, the rostrum of the 
sphenoid, and the triangular cartilage. 

The vomer is rhomboid in shape, its lower margin being united 
with the palatine and nasal crests, the upper short margin deviating 
to form two wing-like projections (alze vomeris), between which 
the rostrum of the sphenoid is inserted. 

The septum is thickest about its lower one-third, at the point 
of junction between the vomer and the palatine and nasal crests; 
the upper olfactory region and the anterior portions of the septum 
are -relatively thin. The choanse are separated by the posterior 
concave margin of the vomer. The perpendicular plate of the 
ethmoid is connected anteriorly with the triangular cartilage and 
posteriorly with the vomer, with which it is blended. 

The cartilaginous septum is irregular in outline, variable in 
size, and separates the anterior portion of the nasal cavities. The 
lower anterior margin lies free (columna nasi). This portion of the 
cartilage is often spoken of as the membranous septum. Its upper 
margin is interposed between the lateral cartilages of the external 
nose, reaching upward as far as the nasal crest. The entire septum 
as far as the columna nasi is covered with mucous membrane. 
The mucosa is firmly united with the periosteum and the peri- 
chondrium, forming a fibromucous membrane which cannot be 
readily separated from its base, especially at the anterior portion. 

The nasal septum receives its blood-supply from the naso- 
palatine, the anterior and the posterior ethmoid and the septal 
arteries, the chief source of supply being the nasopalatine. 

In the mucosa of the septum, in its upper segment, a large 
proportion of the ramifications from the olfactory bulb are situated. 
The sensory nerve supply comes from the first and second branches 
of the trigeminus, the vidian and the nasopalatine branch from 
Meckel's ganglion. The septum serves the double purpose of 
dividing the nasal cavity into two conical or wedge-shaped compart- 
ments, and at the same time serves as an important factor in the 
framework and the general conformation of the nose. 
(518) 




Fig. 306.— The anatomical formation of the nasal septum. 
(From Beaver, with permission.) 

a, Perpendicular plate of ethmoid. d, Septal cartilage. 

b, Sphenoidal sinus. e, Groove for nasopalatine 

c, Inferior lateral cartilage. /. Vomer. 



THE NASAL SEPTUM. 



519 



DEFORMITIES OF THE NASAL SEPTUM. 

The deformities of the nasal septum may be divided into three 
general varieties: 1, those resulting from simple spurs or crests ;- 
2, deviations or deflections; 3, perforations, the result either of 




h 



Fig. 307. — Septal spur parallel with the floor of the nasal cavity. 
The dotted lines indicate the line to be followed in removal by means 
of saw. 

ulceration or traumatism. Added to this the deformity is some-: 
times simulated, either at its base or its upper portion, by an 
accumulation of mucous glands, and by synechia. 




FRONT VIEW 



SIDE VIEW 



Fig. 308. — The cone-shaped septal spur situated upon the vomer. 

Septal Spurs. — Local thickenings and cartilaginous or bony 
ridges on the septum are designated as spurs, which usually appear 
in the form of crests or spines. When the outgrowth occurs on the 
cartilaginous septum it is known as an ecchondrosis, and when 
occurring on the osseous portion of the septum it is termed an 
exostosis. These may be present either with or without deviations. 

Their direction is generally anteroposterior, parallel to the 
floor of the nose (Fig. 307), or projecting at a right angle from the 



520 



XOSE AXD NASAL ACCESSORY SINUSES. 



septum, but occasionally they are vertical. Parker describes a spur 
which is located along the junction of the perpendicular plate of 
the ethmoid with the vomer, and runs in an upward and backward 
direction. 

Another less common form is a cone-shaped offshoot from -the 
vomer, which has a broad base and is located well back upon the 
vomer (Fig. 308). 




Fig. 309. — A deflected septum of normal thickness throughout 
and without spurs or crests. 

Deviations and Deflections. — In early life, up to about the 
seventh year, the septum is practically straight (Fig. 363) in 80 
per cent, of individuals ; it is rarely deviated in primitive peoples. 
In adult life, however, -fully 76 per cent, show deflections, to the left 
more frequently than to the right, and this condition is the corn- 




Fig. 310. — A deflected and thickened septum with a ridge upon each side. 



monest of all the abnormalities found within the nasal cavity. It 
may be described as a permanent bending of the septum from the 
median line, whereby the nasal cavities are no longer divided 
symmetrically, one cavity being widened at the expense of the 
other. 

The variations in form, extent and location are numerous and 
difficult of classification. Two general varieties, however, may be 
described: (a) those in which the septum is of normal thickness 
and unaccompanied by spurs, ridges or crests (Fig. 309) ; (b) 



THE NASAL SEPTUM. 



521 



deflections (with or without thickenings) which are accompanied 
by one or more spurs, ridges or crests (Fig. 310). 

The subdivisions of these varieties are many, depending on 
the location and general direction of the deformity. The more 
common subdivisions are: 1, those in which the deflection assumes 
an anteroposterior direction, the apparent bending being from 
above downward, the concave lower portion assuming an antero- 
posterior direction ; 2, a common variety in which the deflection 
assumes a vertical direction, the line of convexity being also 
vertical (Fig. 311) ; 3, a variety often described as a sigmoid or 
S-shaped deflection (Fig. 312), in which the deformity is so placed 
that the anterior portion of the septum projects into one naris, 
and the posterior portion into the naris of the opposite side; 4, a 
less common but extremely troublesome variety, in which the sep- 
tum assumes a variety of irregular forms difficult to describe, and 
usually resulting from violent traumatism; 5, a type in which the 




Fig. 311. — The vertical deflection of the nasal septum. 



deflection is so situated that the lower (anterior) margin projects 
into the opposite nostril, where it produces obstruction (Fig. 338). 

The subdivisions of the second class are practically the same, 
but in each case the deformity is accompanied by inflammatory 
thickenings in the form of crests or spurs. Coakley 1 has aptly 
illustrated these deflections by making use of a blotter, held with 
the long sides parallel to the floor while the two short sides are 
pressed upon, when the blotter will be seen to bend, the convexity 
now being vertical. The S-shaped deviations of the septum are 
represented by the doubly bent blotter. 

These general forms, in varying degrees, practically represent 
the types to be observed. Considerable variations may take place 
without seriously interfering with respiration and drainage, or 
without inducing pressure symptoms; yet a deflection may be so 
extreme as to render respiration on the affected side impossible, 
and at other times crests or spurs impinge upon the tissues of the 
lateral nasal wall, thereby causing inflammatory and pressure 
symptoms. 



1 Diseases of the Nose and Throat, p. 124. 



522 NOSE AND NASAL ACCESSORY SINUSES. 

Deflections commonly exert severe pressure upon the middle 
turbinal, and even force this structure upward and outward from 
its normal location. 

Etiology. — Various theories have been advanced concerning 
the causation of septal deformities. In many instances, however, 
their advocates have advanced but little proof. The chief causative 
agents in producing septal deformities are : — 

(a) Congenital Malformations. — These occur in but a small per- 
centage of the cases. 

(b) The arrested or the excessive development of the facial bones 
are factors likewise found in a small proportion of the cases of 
septal deflections. Furthermore, the method of septal develop- 
ment is conducive to a variety of deformities which occur as a 
result of facial asymmetry and malformation of the contiguous 
bony structures, especially of the hard palate. 




Fig. 312. — A diagrammatic representation of the sigmoid or 
S-shaped deflection. 

(c) Traumatism, which is probably the commonest factor in 
the etiology of these deformities. The prominent location of the 
nose renders it extremely liable to injury by direct violence either 
during instrumental delivery at birth, or in the accidents of later 
life, the septum suffering by trauma more frequently than other 
parts of the nasal scaffolding. A blow or fall on the nose during 
childhood is often forgotten, and the low grade inflammatory 
process at the site of injury progresses and increases the deformity 
as nasal development progresses. This accounts for the fact that 
in the majority of cases relief is only sought after childhood. 
According to Mosher, "trauma as well as delayed eruption of the 
incisor teeth can displace the premaxillary wings and distort the 
vomer groove, resulting in spurs and causing deviations anteriorly 
and posteriorly." 

Pathology. — Where the irregularity of the septum is due to a 
simple outgrowth or spur, it is defined either as an ecchondrosis 
(cartilaginous), or an exostosis (bony). The ecchondrosis is 
usually found on the anterior portion of the septum and the 
exostosis on the posterior portion. Occasionally a spur may be 



THE NASAL SEPTUM. 523 

both cartilaginous and bony. Ridges or crests are found at different 
places along the lines of junction of the cartilaginous and bony 
portions of the septum, and may project into either nostril. Spurs 
and ridges are usually no hindrance, but may cause more or less 
obstruction to nasal respiration and drainage, or be the points of 
origin for reflex disturbances. 

When the deviations are due to traumatism, the inflammatory 
changes in the perichondrium and periosteum of the septum may 
result in localized thickenings with negative pressure, which in 
turn may induce attacks of catarrhal or purulent inflammation of the 
nasal mucosa and the accessory nasal cavities. 

Symptoms. — The symptomatology varies according to the 
degree of septal deformity. Slight deformity, whether due to spur 
or deflection, produces no symptoms. Where the deflection or 
deviation is marked, external nasal deformity may be noticed and 
symptoms of obstruction, either to respiration or drainage, are in 
evidence.. The patient complains of inability to breathe freely 
through the nose," obstructed breathing being mostly on the side of 
the septal convexity. It is worse at night, and often causes mouth- 
breathing. 

Catarrhal inflammation sooner or later develops behind the 
obstruction, first of the nasal mucous membrane, later of the 
pharynx, and in severe cases it extends to the larynx and bronchi, 
thereby causing discharge, cough and alteration of the voice. Head- 
ache, vertigo and aprosexia may result from the retarded drainage 
of the accessory nasal cavities. High deviations are prone to 
induce frontal headaches, which are more severe in the morning 
hours, in contradistinction to those of ocular origin. 

In young individuals defective development, particularly of the 
chest, and impairment of the general health are among the later 
manifestations. 

Locally there may be itching, discharge and sneezing. Attacks 
of epistaxis are due to the patient's -interference with crusts on 
either the septum or spurs. The sense of smell and taste may be 
impaired or perverted. Tinnitus and chronic catarrhal otitis media 
also are associated with nasal obstruction of septal origin. Of the 
reflex symptoms which are evoked by impingement of the deflec- 
tion or spur upon the turbinal tissues, headache, neuralgia and 
sneezing, rhinorrhea, hay fever and asthma are the chief. 

Differential Diagnosis. — A careful rhinoscopic examination is 
sufficient to determine a deviation or deflection of the septum. A 
concavity is found on one side of the septum, and on the other side 
the corresponding convexity. Upon the concave side the inferior 
turbinal is usually swollen or hypertrophied. At times the external 
contour of the nose is twisted or bent toward the side of convexity. 

Spurs or ridges are differentiated from the simple thickenings 
of the mucous membrane by palpating with the probe. A syphilitic 
gumma of the septum is usually situated on either side of the sep- 
tum high up, and has a boggy feel when palpated. Furthermore, it 
soon disappears under antiluetic treatment. 



524 



XOSE AND XASAL ACCESSORY SINUSES. 



In fractures of the nasal bones, if recent, one can elicit crepitus; 
but in an old fracture as a rule the nasal bones are displaced out- 
ward and the septum appears thickened above and posteriorly. In 
an abscess or hematoma of the septum one usually can obtain a his- 
tory of a recent traumatism, and palpation with the probe will aid in 
differentiating either condition from a septal deviation. Tumors 




Fig. 313. — The Adams forceps 
for overcoming the resiliency 
(crushing) of a deflected septum. 



of the septum, malignant or benign (see Chapter XLII), are 
readily distinguished from either septal deflections or deviations. 

Treatment. — Owing to the character of its structure, surgical 
measures only will prove efficacious for the correction of the 
various deformities of the nasal septum. Surgical interference, 




Fig. 314. — Diagram of Gleason's operation. The traumatism originally 
causing the deflection is practically reproduced by converting the deflected 
area of the septum into a quadrilateral flap : a, Deviated area of the sep- 
tum, surrounded by a U-shaped incision; c, neck or base of the resulting 
quadrilateral flap; b, its inferior edge. (Gleason, with permission.) 

however, is indicated only in those cases in which the deformity 
impedes respiration or obstructs nasal drainage, with or without 
congestive phenomena ; when reflex neuroses or aural complications 
are encountered, or in those cases where it becomes necessary to 



THE NASAL SEPTUM. 



525 



relieve stenosis in order to gain access to the accessory sinuses. 
Occasionally, when the septal deformity is not great, a partial 
removal of the inferior turbinal will suffice to re-establish proper 
nasal respiration and drainage. 

Walsham has well defined the indications for the removal of 
spurs : 1, when they impede free breathing through the nose ; 2, 




when they appear to be the cause of reflex irritation ; 3, when they 
are the seat of ulceration, with or without hemorrhage; 4, when 
they present at the external nares and cause external deformity. 
To these may be added occasional cases when the operation 
becomes necessary in order to allow the introduction of the Eusta- 
chian catheter in the treatment of middle-ear diseases. 

Operations upon the Nasal Septum. — Various operations have 
been devised and recommended for the correction of septal deformi- 
ties, nearly all within recent years. Simple deformities confined to 




Fig. 316. — The vulcanized rubber splint. 



the cartilaginous portion may be corrected by the simpler methods, 
notably reduction by the use of one of the various crushing or 
cutting forceps like those devised by Adams (Fig. 313) and Roe 
(Fig. 315). Some authors advise ..incisions through the septum, 
either parallel or crucial, in order to overcome the resiliency of its 
cartilage, to be followed by adjustment of the Fragments into the 
correct position, where, by means of properly applied splints, they 
are retained until firmly united. Gleason makes a V-shaped bevel 
incision at the base of the septum surrounding the deflected area, 



526 



XOSE AXD NASAL ACCESSORY SIXUSES. 



excepting at the top. This operation is applicable to angular 
deflections which are confined to the cartilaginous septum. 

He describes his operation as follows: "A thin saw is intro- 
duced along the floor of the septum beneath the deviation, the 
sawing is begun in a horizontal direction until the blade has pene- 
trated somewhat deeply into the tissues, when the direction of 
sawing is rapidly changed from horizontal to nearly vertical. It is 
of the utmost importance that the saw should be held exactly 




Fig. 317. — Asch's straight scissors. 

parallel to the septum, in_ order that the cut shall be around and 
not through any part of the deviation. The length of the vertical 
crura is then quickly increased by means of a small bistoury 
curved on its flat, and the flap is thrust through the hole in the 
septum with the forefinger. While the finger is still in the nares 
it is carried up along the anterior and posterior crura, in order to 
be certain that the edge of the flap has completely cleared them, 
and the neck of the flap is then sharply bent. It is not necessary 




Fig. 318. — Asch's angular scissors 



to denude the edges that are in contact, as the pressure results in 
necrosis, at least of the superficial epithelial layer of the mucosa, 
after which the parts unite. 

"The special claim made for this operation is that it destroys 
the resiliency of the flap (a condition of success in any operation) 
at its neck, for it is at this point, and practically here alone, that 
resiliency is active, that is, at the neck of a comparatively long, 
narrow tongue, and hence has a powerful leverage to overcome 
before it can thrust the inferior edge of the flap back through the 
septum. The neck should be bent to nearly a right angle" (Fig. 
314). 



THE NASAL SEPTUM. 



527 



The Roe Operation. — An ingenious appliance for overcoming 
the resiliency of a deformed septum is found in Roe's forceps (Fig. 
315), which is so constructed that powerful pressure may be 
brought to bear upon the deformity, the female blade being intro- 
duced into the concave side and the male blade upon the convex. 
The instrument is so devised that almost perfect control of the 
amount of pressure and crushing may be obtained. The success 
of the operation depends largely upon the ability of the operator to 
break down the deformed portions of the septum, and it is further- 
more enhanced by the employment of some form of splint, several 




Fig. 319. — Asch's septum forceps. 

varieties of which are upon the market. The splint is to be retained 
and the nasal chamber firmly fitted until healing has taken place. 
The author recommends a splint to be constructed of vulcanized 
rubber at the time of operation. This splint is constructed from 
a sheet of about % 6 of an inch in thickness, which when soaked in 
hot water becomes flexible enough to be cut with scissors and to 
be molded cylindrically, the edges becoming at the same time 
adhesive enough to stick together in any desirable shape; hence 
for nasal splint purposes it can be made to fit exactly the case in 
hand (Fig. 316). 

The Asch Operation. — For some years, especially in the United 
States, the Asch operation was generally employed to correct the 




Fig. 320. — Mayer's nasal tube splint. 



more severe deformities of the septum. Asch, in 1890, reported 
six successful operations by his method. He devised for the opera- 
tion two separators, a sharp and blunt one, two scissors, one with 
straight blades (Fig. 317), the other with the blades at a right 
angle to the handles (Fig. 318), and a long and short blunt forceps 
(Fig. 319), and also vulcanite tubes to fit the nasal cavity and act 
as splints (Fig. 320). 

After the patient is anesthetized, the head is drawn well back 
to avoid the entrance of blood into the larynx. With good illumi- 
nation a separator is introduced into the occluded nares to break 
up any adhesions that may exist between the septum and tur- 



528 



NOSE AXD NASAL ACCESSORY SINUSES. 



binals. Hemorrhage may be free unless adrenalin is applied 
previous to anesthesia. 

The straight scissors are now introduced into the nasal cavity, 
parallel to the nasal floor, the cutting blade over the concavity of 
the septum and the blunt blade over the greatest convexity of the 
septum. The handles are then compressed, cutting through the 
cartilage. The scissors are now opened up and removed from the 
nasal cavity. The same scissors may be used for the next step, but 
it is more practicable to use the scissors with the right-angle 
blades ; these scissors are now introduced into the nasal cavity, 




Fig. 321. — Schematic representation of the two incisions in 
the Asch operation. 



with the blades at a right angle to the first incision, and at about 
its centre ; the blades are closed, thus intersecting the first incision, 
and the scissors withdrawn. This results in a crucial incision of 
the septum over the deflection with four segments (Fig. 321). 
With a finger introduced into the nasal cavity over the septal 
convexity these segments are broken at their base and pushed over 
into the concavity of the opposite side. 

The next step is the introduction into each nostril of a blade 
of the blunt forceps (Fig. 319), which are then brought together, 
thus straightening the septum and forcing the broken segments 
to override each other in the concavity. An iced antiseptic or 
saline solution may be sprayed into the nose to check the hemor- 
rhage, but usually the hemorrhage ceases when the next step is 
carried out, viz., the introduction of the sterile splint tubes (Fig. 
320), a close-fitting one being pushed into the nasal cavity in which 



THE NASAL SEPTUM. 529 

the stenosis existed, and a smaller one into the opposite nostril to 
equalize the pressure and likewise to splint the fractured septum. 

The patient is placed in bed and ice cloths are applied to the 
nose. After twenty-four hours the smaller tube from the concave 
side is permanently removed. The cold applications are continued. 
After forty-eight hours the larger tube is removed from the stenosed 
side for the purpose of cleansing and sterilization, and also in order 
to cleanse the nose, either by spraying or with a cotton applicator 
saturated with saline or antiseptic solution. Cocaine solution (4 per 
cent.) is now applied to the stenosed side and the same tube rein- 
serted if it is possible to do so without using force; otherwise a 
smaller tube must be selected. The tube should not project from 
the nostril. 

After the second or third day the cold external applications are 
abolished and the patient allowed to be up, and on the fourth day 
he may be dismissed from the hospital. The tube is removed, 
cleansed, the nasal cavity cleansed,, and the tube reinserted daily 
for the next four or five weeks. After the first week this may be 
carried out by the patient if well drilled in the cleansing procedure 
as here outlined. After five weeks the tube splint is entirely dis- 
pensed with as the cartilage is united and the septum straightened. 
If the lower segment of cartilage still projects after the tube has 
been permanently discarded it should be removed with the saw. 
The patient may follow his usual pursuit after the third day, inas- 
much as the tube splint allows free nasal respiration, and is worn 
with comparative comfort. 

The results of these operations when thoroughly performed are 
good in cases which are unaccompanied by displacement of the 
vomer or the perpendicular plate of the ethmoid, or by unusual 
thickenings of the maxillary ridge. It is practically impossible to 
fracture the maxillary ridge except to a slight degree, and fractures 
of the vomer made by forceps rarely take the desired direction. 
Hence in cases of the latter types the submucous resection operation 
is preferable. 

Deflections confined to the cartilaginous portion of the septum 
often are amenable to the Gleason operation. The Roe forceps, 
however, overcome this form with better results. The Asch opera- 
tion has the disadvantage that it is exceedingly painful, requires a 
general anesthetic, and is attended with a considerable loss of 
Idood. The crucial incisions, while effective, are liable to result in 
septal perforations; it also requires a prolonged use of a retention 
splint with the necessity for almost daily treatment. Roe's forceps 
overcome the resiliency of the cartilage without cutting, the hemor- 
rhage is slight, and a retention splint is not needed for so long a 
period. To this extent it is superior to the methods requiring 
incisions. The majority of cases receive sufficient benefit from a 
well-performed Roe or Asch operation to commend their use in 
selected cases. 

Submucous Resection of the Nasal Septum. — The submucous 
resection operation contemplates the complete removal of the car- 



530 NOSE AND XASAL ACCESSORY SINUSES. 

tilage and bone which compose the deformed part of the septum, 
allowing the perichondrium and mucous membrane of either side 
to fall tog-ether and form a septum without its intermediary frame- 
work. Hence this operation differs materially from those heretofore 
described. 

In preparing- the patient for a septal operation all hair should 
be clipped from both nasal vestibules. This procedure is an aid 
to cleanliness and it gives the operator a clearer view of the deeper 
portions of the nasal cavities. The nasal cavities should then be 
thoroughly cleansed with a normal saline solution, and the upper 
lip, the nose, the adjacent areas, and the vestibules should be 
painted with iodine, followed by a wash of alcohol. Twenty grains 
of sodium bromid administered a half-hour before the operation acts 
as a sedative and to that extent adds to the patient's comfort. 

The length of time taken to properly perform the operation 
is from twenty minutes to one hour, and it never should be under- 
taken unless the operator has sufficient time to work with delibera- 
tion. It is preferably performed under local anesthesia, inasmuch as 
the hemorrhage rarelv is sufficient to interfere with the work, the 






Fig. 322. — Ballenger's mucosa knife. 

field may the more easily be illuminated, and the patient in various 
ways is thereby enabled to render valuable assistance, especially in 
changing the position of his head. Cocaine or alypin, in solution 
of 5 to 20 per cent, combined with adrenalin chlorid solution, from 
1 : 5000 to 1 : 1000, applied to both surfaces of the septum for about 
twenty minutes, may be relied upon to completely anesthetize the 
septal tissues. The crystals of cocaine, when rubbed upon the septal 
surfaces with a pledget of cotton moistened (Freer) in adrenalin 
solution, 1 : 100, will more rapidly produce anesthesia, and are 
thought to block the vascular and lymphatic channels of the mucosa, 
and so prevent systemic poisoning from absorption of the local 
anesthetic. 

The most practical mixture for local anesthesia in the nose is 
made by mixing equal parts of a 10 per cent, cocaine solution and a 
1:1000 adrenalin chlorid solution. This combination produces a 
mixture containing 5 per cent, cocaine and adrenalin chlorid 1 : 2000. 
This combination is ample for prolonged local anesthesia, is safe and 
can be freely applied by means of cotton pledgets. The hypodermic 
injection of a few drops of a l /i of 1 per cent, solution of cocaine 
underneath the mucochondrium at various points, but particularly 
at the area of the primary incision, not only induces rapid anesthesia, 
but, by partially separating the mucochondrium from the cartilage, 
renders valuable assistance in that step of the operation. 

A\ Tiile the operation may thus be performed without actual 
pain, the suffering- of the patient should never be lightly considered, 



THE NASAL SEPTUM. 



531 



inasmuch as, almost invariably, rather severe shock attends this 
operative procedure. It is often necessary to administer a stimu- 
lant in the form of whiskey or a dram of the aromatic spirits of 
ammonia if the patient feels faint, or he should be allowed to lie 
down for a few minutes. The discomforts which arise from faint- 
ness and shock may largely be obviated by placing the patient upon 
an operating' table, with the headrest elevated to the highest posi- 
tion. Furthermore this position does not materially interfere with 
the technique of the operation. The operation preferably should 
be performed in a hospital, so that the patient immediately may 
retire and remain in bed until the following- day. If done in the 
operator's office, the patient should be taken to his home in a car 
or other conveyance and not allowed to walk through the streets. 




YANKAUER 
KILL1AN 



HAJEK 



Fig. 322a. — Showing the line of incision employed by 
Hajek, Killian, and Yarikauer. 



Operation. — The primary incision through the mucous mem- 
brane and the perichondrium is, by most operators, made upon the 
convex surface. 

Thejocation of the incision, its length and its direction may be 
left to the individuality of the operator so long as the cartilage is 
finally exposed and incised well in front of the septal band. 

The incisions recommended by Killian, Hajek and Yankauer are 
similar, the latter extending the lower limit across the floor of the 
vestibule (Fig. 322a), while that of Freer (Fig. 322b) is termed the 
reverse L-incision. 

In following the Freer plan a horizontal incision is made ah nig 
the base of the septum al its junction with the nasal floor, extending 
about one inch from the mucocutaneous junction within the vesti- 
bule. A vertical incision is then made to intersect with the inner 
end of the horizontal one, but during the process of elevating the 
mucochondrium a small segmem between the intersecting points of 
the two incisions should be left intacl (Fig. 322&). 

Having completed the elevating of the mucochondrium the 



532 



NOSE AXL) NASAL ACCESSORY SINUSES. 



small segment is cut and the flap is reflected forward and upward, 
where it is held by a retractor. 

If one of the incisions first mentioned has been employed, 
the mucous membrane and perichondrium of the corresponding side 
should then be separated from the cartilage by means of special 
elevators (Fig. 323), which should he moved in an upward and 
downward direction in their long axis in order to prevent accidental 
perforation of the mucous membrane. By completing the separa- 
tion with the long edge of a blunt elevator, the mucochondrium 
and periosteum are stripped from the septum. 

Having separated the mucous membrane from the septal 
cartilage over a wide area upon the side of the primary incision a 




Fig. 322b. — Freer's L-shaped incision for the submucous resection 
operation. Note the point which remains uncut until the balance of flap 
has been elevated. 



vertical incision is made through the cartilage to the perichondrium 
of the opposite side, following the line of the primary incision in the 
mucous membrane. Great pains should he taken not to wound the 
mucous membrane of the opposite side. A safer method is to scrape 
through the cartilage to the perichondrium of the opposite side with 
a small curet (Yankauer) (Fig. 324). Through this incision or 
excavation in the cartilage a small elevator is passed, and the peri- 
chondrium and mucosa are carefully separated from a similar area 
upon the opposite side of the septum (Fig. 326). This must be 
done with extreme care and deliberation in order to avoid tearing or 
bruising the mucous membrane, with the attendant danger of 
sloughing or perforation. 

When the mucochondrium has been well separated from 
the septum. on both sides, the cartilage is removed piecemeal with 



THE NASAL SEPTUM. 



533 



a cutting forceps, or preferably in its entirety (Fig. 325) with the 
Ballenger swivel knife (Figs. 326 and 327). This instrument is per- 
fectly adapted to this purpose, it is entirely safe and it shortens the 
time of operation. The procedure up to this point, however, must 
be considered as preliminary to the real operation, which con- 
sists in the removal of the deflected portions of the vomer, the 



Fig. 323. — Perichondrium elevators, a, Ballenger's. b, Freer's. 

perpendicular plate of the ethmoid and the maxillary ridge. Spread- 
ing open the primary incision through the membrane, the oper- 
ator will easily see the projecting edge of the cartilage that 
remains, or if all the cartilage has been removed the edges of the 
vomer come into view. Sharp cutting forceps (Fig. 328) should 
now be carefully introduced and the balance of the deflection re- 



Fig. 324. — Small oval curet for penetrating the septal cartilage. 

moved. The two mucosa curtains are best held apart by either 
Killian's long submucous speculum (Fig*. 329) or one of the various 
retractors (Fig. 330) devised for this purpose (Fig. 331). 

To gain access to the maxillary ridge a sharp separator is often 
necessary for the purpose of separating the periosteum along the 
floor; Yankauer's instrument (Fig. 332) is useful for this manipula- 



Fig. 325. — Specimen of s 




removed with the swivel knife. 



tion. The ridge is removed either by cutting forceps (Fig. 333) or 
the Hajek crotch chisel (Fig. 334) driven with a mallet. The 
latter (Fig. 33?) is more accurate and hence is preferable for the 
removal of tin- ridge, ami a large portion of this bony tissue should 
be excised. For the vomer and ethmoidal portions the various 
punch forceps or small, slender rongeur forceps serve the purpose. 



534 



NOSE AND NASAL ACCESSORY SINUSES. 



The full measure of success depends upon the complete removal of 
all parts of the septal framework which enter into the deflection or 
obstruction. 

In removing- the cartilaginous portion of the septum it is 
advisable to retain sufficient cartilage along the bridge of the nose 
and the frenum to maintain its symmetry, and thus avoid the so- 
called "saddleback" nose. 

After complete removal of bone 
and cartilage, the operative field 
between the mucous membranes 
is douched with normal saline so- 
lution in order to wash out the 
debris of excised cartilage ; then 
the surfaces of the mucochon- 
drium should he drawn together 
and the cut edges approximated as 
nearly as possihle. Sutures should 
be employed whenever they may be 
utilized to prevent perforations. 
The Jansen curved needles are ad- 
miral )ly adapted for this purpose. 
The convex side is packed well 
hack with sterile vaselin gauze, or 
a strip of sterile rubber tissue is 
first pushed well back in the nasal 
cavity where the convexity existed, 
2nd against this rubber tissue suf- 
ficient plain sterile gauze is packed 
to (ill the cavity. The vaselin gauze 
and the rubber tissue prevent ad- 
hesion of the packing to the mu- 
cous membrane, and likewise make 
the removal of the dressing easier; 
the opposite nostril should be similarly but lightly packed. The pack- 
ing lessens the tendency to postoperative hemorrhage and prevents the 
formation of hematomata. 




Fig. 326. — The mucochondrium 
has been separated from both sides 
of the cartilage in accordance with 
the description in the text. The 
Ballenger swivel knife is inserted 
into the cartilage incision pre- 
paratory to its removal. (Partly 
schematic.) 



.—The iialh 




Secondary hemorrhage is rare. Ballenger introduces a Simpson 
sponge tent (Fig. 342) into each nostril instead of the gauze packing, 
and removes them in from twenty-four to forty-eight hours. 

After-treatment. — The patient should remain in bed until the 
following day, and the further after-treatment should consist in the 
removal of the packing after twenty-four to forty-eight hours, the 
packing being thereafter dispensed with. The nasal cavities are 
douched daily for cleansing purposes with a normal saline solution. 
A Douglass douche bag (Fig. 336), or the Fowler nasal douche 



THE NASAL SEPTUM. 



535 



(Fig. 304), is practical for this purpose, but violent "blowing" of 
the nose should be avoided for some time after douching. 

Sutures should be removed about the third day. The inci- 
sions heal in from four to seven days when the mucous membrane 




Fig. 328. — Foster-Ballenger bone 
cutting forceps for removing portions 
of the vomer. 



has not been torn ; otherwise granulations appear and final healing 
is delayed. Slight postoperative thickenings about the maxillary 
ridge often disappear by absorption after a few weeks. 




Fig. 329. — Killian's submucous speculum. 



Yankauer's instruments, which are illustrated in Fig. 337, facilitate 
the submucous operation, and need no further description. 

With the exception of the resection operation, the above- 
described operative procedures depend upon some form of crushing 



r 



Fig. 330. — Submucous band retractor. 



or breaking of the septal cartilage for the purpose of overcoming its 
resiliency. They, therefore, represent one general type of operation, 
while the submucous resection accomplishes the result by means of 
the removal of a large portion of the septal cartilage, together with 
the bone deformities which exist in the individual case. 



536 



NOSE AND NASAL ACCESSORY SINUSES. 



The Comparative Value of the Various Septal Operations. — 

The submucous operation is difficult. Much skill and consid- 
erable time is required in its performance, but the healing is 
wonderfully prompt. The submucous resection rarely fails to 




Jig. 331. — Allcn-Heffermann's 
submucous speculum. 



relieve the stenosis, but it may be' attended with serious complica- 
tions or sequelae. A few deaths from meningitis recently have been 
reported as a result of this operation; hence it should be performed 



Fig. 332. — Yankauer's periosteum elevator. 

only under strict asepsis, and at all times it should be considered a 
major surgical procedure. While some untoward results may fol- 
low any operation for correction of deviated septa, not all, however, 
can be attributed to the operation per se. These complications are 




forceps. 



hemorrhage, hematomata, erysipelas, follicular tonsillitis, inflamma- 
tion of the accessory sinuses, fauces or larynx, unintentional injury 
to neighboring parts, septal perforations, synechia or atresia of the 
nasal passages, septal absces and hematomata. 

In comparison, the Asch operation requires a general anesthetic; 



THE NASAL SEPTUM. 



537 



it is attended with severe hemorrhage; it necessitates a tedious 
after-treatment and much discomfort to the patient on account of 
the splints or packing. Furthermore it is not always attended by 
complete relief of the stenosis, and perforations are common. 

The Roe operation in the simple deflections is. easily performed ; 
local anesthesia is sufficient, but the splint is necessary. 

The author believes that the Roe or Asch operation is still to 
be preferred to the submucous resection in cases of deflections with 




Fig. 334. — The crotch chisel applied to the maxillary ridge, 
where the same already 



ell 



a tendency to atrophic rhinitis 

marked in the concave nasal cavity. In such cases to remove the 
thickened septal deformity would only increase the atrophic condi- 
tion and so add to the patient's distress rather than give the desired 
relief. 

Anterior Dislocation of the Columnar Cartilage. — The treatment 
of the type in which the lower (anterior) margin of the septal car- 

IL^^LUJMUllJlMJUU'i'll'Hijiiiiiii iiiiiH iili III! Uliii '1'iUU iUjl^ 
Fig. 335. — The Hajek septal chisel. 

tilage projects into the nostril is conducted as follows: 1. Make an 
incision along the line of the free border of the cartilage. 2. Retract 
the soft tissues and perichondrium from both (lateral) sides for a 
considerable distance. 3. Remove the projecting portions of the 
cartilage with the Ballenger swivel knife (Fig. 338) or scissors. 
4. Close the wound by means of sutures. 

The Removal of Septal Spurs.— A majority of the deviations of 
the septum are accompanied by spurs or ridges, but the latter com- 
monly occur independent of the deviation or deflection. These are 



538 



NOSE AND NASAL ACCESSORY SINUSES. 



composed either of bone or cartilage, or of bone and cartilage com- 
bined. They occur in various forms, sizes and locations, the 
maxillary ridge furnishing the larger proportion. They are often 
of large size and impinge upon the turbinal or lateral nasal wall 
(Fig. 330). One form often overlooked, unless the soft tissues are 
fully contracted, is the cone-shaped spur heretofore mentioned 
(page 520) situated far back upon the vomer. 

Where small spurs are present at the 
time a submucous operation is contemplated, 
it is advisable to remove them through the 
incision after the mucochondrium has been 
separated. 

Large spurs, however, may require re- 
moval either at the time of the major operation 
or some time thereafter. Several methods 
have been advocated for the removal of septal 
spurs, and various trephines, burrs, saws (Fig. 
340) and other cutting instruments have been 
devised for the purpose. The instrument in 
common use is the saw, whereby the entire 
spur is completely severed at its base. The 
same results may be obtained by means of the 
electric trephine, burr or dental drill. Many 
operators have advised a submucous resection 
of the spur by making a primary incision 
through the mucous membrane and perichon- 
drium, to be followed by complete retraction 
of these tissues over the entire surface of the 
spur, so that after the removal of the under- 
lying spur the membranes may be allowed to 
fall over the resultant exposed surface. Theo- 
retically, this procedure seems wise, but the 
claims are not usually fulfilled, chiefly for the 
reason that the membrane is usually consider- 
ably thickened, and thus covers space which 
could be utilized for the ventilation of the 
nostril. In the author's experience the re- 
moval of the entire spur, membrane and all 
close to its base, while requiring considerable 
time for a final healing, rarely results either in ulcer or troublesome 
scar tissue. As a rule a healthy, smooth surface results. Whenever a 
spur has an unusually broad base an exception should be made and that 
portion of the mucochondrium lying above the level of the utmost 
projection of the spur should be elevated by means of a lineal incision, 
and periosteum elevators, and the same retracted during the sawing 
process. After removing the spur the loose membrane should be 
drawn downward over the denuded surface. 

The patient should be prepared by thorough cleansing of the 
nostrils and the surrounding outer surfaces near the nose. A solu- 
tion of cocaine or alypin and adrenalin in the proportion already 




Fig. 336. — The Douglass 
douche bag. 



THE NASAL SEPTUM. 



539 




nniTHjiJlttl^ 



=3 



Z) 



a 




: TTmi,-.-.-.ii",-,ii.'.!iii.unnm> 



i I...ZIZZZ.IZ2JZ. ' ~TT ~7B 



cd 



=3 



20 



* > 




540 



NOSE AND NASAL ACCESSORY SINUSES. 



recommended in this chapter should be applied to both sides of the 
septum by means of cotton pledgets (Fig. 347), after the manner 
described in Chapter XXXVI. The time requisite for anesthetiza- 
tion is about twenty minutes, after which the operation may be 
performed with a sharp saw (Fig. 341) without pain. The under 
surface of the spur is usually a rather sharp ledge. The removal is 
therefore preferably accomplished by sawing from below upward. 
It is important to continue the line of removal parallel with the 




Fig. 338.— Removal of the projecting free border of the septal cartilage. 



septum, as there is a tendency for the saw to gradually curve 
outward (Fig. 307). 

The removal of septal spurs often causes considerable hemor- 
rhage. This usually subsides spontaneously, but an occasional 
spurting of blood may require tampons (Fig. 342) or packing 
(Chapter XL). 

As soon as the saw has passed through the hard tissue it is 
well to complete the excision with a slender pair of angular scissors 
(Fig. 343). If the resultant surface is smooth the operation may be 
considered completed, but if a small projection of bone remains it 
should be removed with a saw or some sharp cutting instrument. 
The wound should now be cleansed with physiological salt solution. 
The majority of authors advise that no dressing of any kind be em- 



THE NASAL SEPTUM. 



541 



ployed. The author does not hold this view, but completes the 
operation by laying over the cut surface a small strip of sterile 
gauze which has been dipped into a solution of acetotartrate of 
aluminum (12 per cent.). His reasons are that it covers the cut 
surface with a sterile and slightly astringent dressing, 'and, while 




Fig. 339. — Septal spur which impinges upon the inferior turbinal. 

not in any sense considered as packing, the subsequent inflammatory 
reaction following the operation makes sufficient pressure between 
the turbinals and septum to hold this in place and practically con- 
trol the hemorrhage which might otherwise occur. 

This is left in situ for from one to two days. So far as the 
results are concerned this form of dressing prevents secondary 




Fig. 340. — The Cosworth nasal saw. 



hemorrhage and infection. Furthermore it lessens the danger of 
synechiae and subsequent granulations. The question of secondary 
hemorrhage is considered in Chapter X L. 



PERFORATIONS OF THE SEPTUM. 

There are two general varieties of septal perforations: 1, those 
in which the cartilaginous portion only is involved, and. 2, perfora- 
tions involving the bony portions. 

The first class constitutes the larger proportion, and as a rule 



542 



NOSE AND XASAL ACCESSORY SINUSES. 



the perforations are oval and are located just beyond the vestibule, a 
little above the floor of the nose (Fig. 344). They are usually the 
result of rhinitis sicca, attacks of diphtheria, syphilis, tuberculosis, 
typhoid fever, a septal abscess, gangrene, the electric cautery, caus- 
tics, and surgical operations. Certain drugs cause necrosis of the 
cartilage, e.g., phosphorus or mercury and the caustic action of 




The Payne nasal saw. 



chromic acid. A perforation usually commences as a slight ulcer, 
produced by the action of an irritating current of air, or from pick- 
ing the nose. Continued efforts to remove the inspissated masses 
covering the ulcers result in still deeper excavations, until finally 
perforations occur. Rhinitis sicca produces a condition of the 
membrane which renders it peculiarly liable to become ulcerated. 
The proportion of ulcerations following typhoid fever is large. The 
tendency to pick scabs following the removal of spurs may result 
in ulceration and subsequent perforation. 




Fig. 342. — Simpson's (Berney's) sponge tampon. 



Perforations involving the bony portions of the septum are 
usually the result of syphilitic necrosis, and in rare instances of 
tuberculosis, lupus, phosphorus or mercurial poisoning. 

The chief symptom of a cartilaginous perforation is the block- 
ing up of one or both nasal passages with scabs or crusts which 
accumulate upon its margins. These crusts by their size not only 
obstruct nasal respiration, but produce a tickling or itching sensa- 
tion which impels the patient to attempt their removal. After a 
time these removals are followed by small hemorrhages and still 
further destruction of cartilage. An annoying symptom some- 
times observed in small perforations, especially with deflections, is 
respiratory whistling. The simpler forms of perforations are not 
accompanied by external deformity. In the more severe forms 



THE NASAL SEPTUM. 543 

(usually syphilitic) wherein the cartilaginous septum and portions 
of the bony septum have succumbed to necrosis, serious external 
deformity results. These deformities assume different types, some- 
times resulting in what is known as a saddleback nose (.Fig. 416), 
and occasionally the entire soft portions of the nose, no longer sup- 
ported by cartilages, fall and produce ugly deformities. 

During the progress of the necrotic process, a copious dis- 
charge of purulent, fetid matter takes place. The diagnosis never 
is difficult, inasmuch as rhinoscopic examination readily reveals the 
perforation. The edges of the perforation are sometimes granular 
and bleeding, but in old perforations the edges are entirely healed 
and covered with whitish, new-formed connective tissue. 

Prognosis. — A septal perforation, except one exceedingly small, 
and unattended with ulceration, rarely fills in. Occasionally, in 
traumatic cases with small perforations, a suture properly applied 
may result in closure. 




Fig. 343. — Knight's angular scissors. 



Treatment. — In cartilaginous perforations with healed edges 
no treatment should be attempted except for removal of the crusts 
by means of bland sprays. In more recent perforations, accom- 
panied by granular or ulcerated edges, attempts should be made to 
induce healing and thus prevent further destruction of cartilage. 

Goldstein has devised a plastic flap operation in which, after 
having trimmed or pared the free edge of the mucous membrane 
from the border of the perforation, he elevates the mucoperichon- 
drium from its attachment about the free border of the perforation 
upon both sides, for a distance of about one-half inch. He then 
resects the rim of cartilage thus exposed, using the hallenger single- 
tined swivel knife. 

A flap of mucous membrane, the dimensions of which are 
larger than the original perforation, is then lifted from a convenient, 
contiguous portion of the septum, and is swung and lilted into the 
space from which the ring of cartilage was resected. A few inter- 
rupted sutures are introduced in order to hold it. in place. It is 
obvious that one side of this flap must heal by granulation from 
the borders of the surrounding membrane. 

Chevalier Jackson has suggested a plastic procedure for closing 
septal perforations by transplanting sufficient tissue from the 
inferior turbinal. 



544 



NOSE AXU XASAL ACCESSORY SINUSES. 



Patients with perforations should always be cautioned against re- 
moval of scabs by means of picking. The scabs should first be softened 
and loosened by bland sprays and then be blown out. The denuded 
surfaces should be painted with a solution of nitrate of silver 20 grains 
to the ounce. Applications of a 2? per cent, solution of ichthyol, and 
a 2 per cent, to 5 per cent, ointment of menthol in white vaselin has a 
healing effect. 

Whenever granulation tissue is found it should be scraped away 
and the basal surface touched either with fused chromic acid or nitrate 
of silver, or a solution of 50 per cent, lactic acid. Perforations at- 
tended with necrosis of the bony septum require a preliminary removal 

of all necrotic bone by means of 
the curet, in connection with such 
internal treatment as the nature of 
the associated constitutional dis- 
ease 1 requires. 

ULCERATIONS OF THE 
SEPTUM. 

The septum may be the seat 
of superficial or deep ulceration, 
the latter usually resulting in per- 
foration. When due to syphilis or 
tuberculosis it may eventuate in 
extensive necrosis of the adjacent 
intranasal structures. Superficial 
ulcers are prone to develop upon 
the convex surface of a deflected 
septum, primarily in consequence 
of the irritation of the air current 
and by the particles of dust which 
it contains. The ulcers are aggra- 
vated by the constant attempts of 
the patient to remove the crusts 
by picking the nose. 
Treatment. — The patient should be cautioned against picking the 
nose and advised to use some bland alkaline or antiseptic wash for the 
purpose of softening and removing the crusts, after which 25 per cent, 
ichthyol or the 2 per cent, to 5 per cent, menthol ointment should be 
applied to the denuded surface. They may, after thorough cleansing 
and drying, lie covered with aristol or iodoform with good results. 
Exuberant granulations about the edges should be destroyed with 
chromic acid or acid nitrate of mercury. Deep ulcerations are prone 
to result in perforations. 

HEMATOMA OF THE SEPTUM. 

A hematoma of the septum is an extravasation of blood, between 
the mucous membrane and the cartilage, as a result of an injury to 
the nose. Tf small, they disappear In' absorption ; if large, they undergo 
organization and produce septal thickening. Tf they become infected, 




Fig. 344. — A perforation of the car 
tilaginous septum. 



THE NASAL SEPTUM. 545 

abscess results. Hematomata of the septum, unless of small size, pro- 
duce marked obstruction to nasal respiration. A large, oval, fluctuat- 
ing tumor, immediately following an injury, is sufficient to establish a 
diagnosis. It is differentiated from abscess by its brief duration. The 
prognosis, except when infection takes place, is good. 

Treatment. — When of considerable size the clot should be re- 
moved by free incision. The cavity should be irrigated with an anti- 
septic solution, and its surfaces held together by pressure for a period 
of three or four days. The dressing should be changed as often as is 
necessary to keep the entire surface clean. 

ABSCESS OF THE SEPTUM. 

Abscess of the septum is an accumulation of pus in the septum, 
with or without destruction of portions of the cartilage. It is usually 
the result of traumatism, with sufficient abrasion to allow the entrance 
of pathogenic micro-organisms. If allowed to remain without incision, 
the deeper structures become necrosed and perforation may result. The 
symptoms are a sensation of fullness, interference with respiration, 
pain, heat, and sometimes rise of body temperature and chills. Upon 
examination a fluctuating tumor is observed in one or both nostrils. A 
foul, mawkish odor is noticeable. The surface of the abscess may be 
bright red or slightly yellow. 

Prognosis. — Early incision and evacuation usually effects a cure, 
with but little destruction of tissue and no external deformity. De- 
layed cases wherein the cartilage has succumbed to the purulent 
process may be followed by a perforation of the septum and even suffi- 
cient loss of cartilage to cause external deformity. 

Treatment. — Incision and evacuation is the only treatment. The 
incision should be followed by thorough cleansing of the cavity and 
the curetment of all necrosed areas and the introduction of a small 
strip of gauze for drainage. Very commonly the pus quickly reaccu- 
mulates, in which event a second incision becomes necessary. 

The after-treatment consists in maintaining the apposition of the 
abscess surfaces by packing the nasal chambers with iodoform or plain 
sterile gauze ; the gauze is removed daily. 

ADHESIONS (SYNECHIA) OF THE SEPTUM. 

Adhesions or synechias are due to traumatic or inflammatory 
causes whereby the septum and outer nasal wall are injured simul- 
taneously. They may result from syphilis, tuberculosis, diphtheria, 
foreign bodies, external violence or intranasal operations. They are 
prone to follow the removal of septal spurs, in patients who neglect the 
after-treatment. Various synechia? are depicted in Fig. 362, and the 
treatment is outlined on page 565. 



35 



CHAPTER XXXVI. 
THE TURBINATE BOXES. 



SURGICAL AND PATHOLOGICAL ANATOMY. 

The turbinate bones are three processes projecting into the 
lumen of the nasal cavity from the lateral nasal wall, to which they 
are attached (Fig. 345), and which comprises the nasal process and 
internal surface of the superior maxilla, the lachrymal, palate and 
sphenoid bones. The turbinate bones are ranged one above the 
other in a nearly longitudinal direction. 

The inferior turbinal (Fig. 345) only is a distinct bone, and is 
the largest and thickest of the three. Its conformation is scroll-like 
and under normal conditions its surface is free from contact with 
the nasal septum, the floor of the inferior meatus, or the lateral 
nasal wall, except at the line of attachment thereto. It extends 
from the inner margin of the vestibule to the posterior nares. 

The middle turbinal (Fig. 345) is shorter than the inferior 
by about one-third. Its location is above and parallel to the pos- 
terior two-thirds of the latter. It arises from the lateral mass of 
the ethmoid bone, and should be considered as part of the ethmoid 
system. 

The superior turbinal is the smallest of these processes, and 
also arises from the lateral mass of the ethmoid bone. It occupies 
a portion of the posterior and superior third of the nasal cavity. 
Its anterior portion is higher and occupies a position about opposite 
the tendo-oculi. 

In rare instances a rudimentary fourth turbinal is found higher 
up, lying parallel with the superior. 

These scroll-like processes are subject to considerable variation 
in size and shape, and, with their covering of mucous membrane, 
blood-vessels, nerves and other soft tissues, are known as the 
turbinals. 

They are employed as landmarks for the purpose of subdividing 
the nasal cavities anatomically into three portions, which are termed 
the inferior, middle and superior meatuses. 

The inferior meatus (Fig. 345) is that portion of the nasal 
cavity below the inferior turbinal and contains the nasolachrymal 
duct, at a point about one inch behind the anterior nasal orifice. 

The middle meatus (Fig. 345) is the portion of the nasal cavity 
lying between the middle and inferior turbinals, into which open 
the ostium maxillare, the anterior ethmoidal cells and the infun- 
dibulum. This meatus is open above, behind and beneath, and 
therefore allows free access to the inhaled air. 

The superior meatus (Fig. 345) is the pathway which extends 
between the superior and middle turbinals, into which open the 

(546) 



THE TURBINATE BONES. 547 

sphenoidal sinus and the posterior ethmoidal cells. It is closed in 
front and opens only downward and backward. 

The arterial supply of the lateral nasal walls, including the 
turbinals, is derived from the anterior and posterior ethmoidal 
branches of the ophthalmic, and the sphenopalatine branch of the 
internal maxillary. 

The sensory nerve supply of the turbinals and the lateral nasal 
wall is furnished by the anterior ethmoidals, the dental branch of 
the superior maxillary and branches of the Vidian nerve. 

The nerves of special sense are composed of a set of branches of 
the olfactory nerve, which spread on the superior and the upper 




Fig. 345. — Vertical coronal section of the skull, with key plate. 



portion of the middle turbinals and branches of the sphenopalatine 
gang-lion, which terminate in the mucosa of the inferior and middle 
turbinals and the inferior surface of the superior turbinal. 

PHYSIOLOGICAL FUNCTION. 

The most important portion of the mucosa lining the respira- 
tory region of the nose is the part covering the inferior turbinal 
and about the lower two-thirds of the middle turbinal. This some- 
times is described as the respiratory portion of the nasal fossa. 
In this locality the membrane is dense, with increased vascularity, 
while in the upper or olfactory region the membrane is thin, 
delicate and has less tendency to hypertrophic changes. This 
variation in the character of the mucosa is explained by the large 
proportion of veins located in the submucous layers over the middle 
and inferior turbinals, and also by the fact that the membrane in 
this locality is characterized by the presence of cavernous spaces 
and erectile tissue. The erectile tissue is located chiefly along the 
inferior surface and posterior end of the inferior turbinal. The 



548 



NOSE AND NASAL ACCESSORY SINUSES. 



cavernous spaces and the erectile tissue permit an enormous disten- 
tion with blood. Hence any pathological changes of the mucosa in 
this region seriously affect the respiratory function of the nose and 
give rise to local as well as general disturbances. The peculiar 
vascular supply of the turbinals produces the phenomenon of erec- 
tion and collapse whenever these tissues pass through a period of 
congestion or anemia of the venous sinuses. The same arrangement 
of the vascular supply of the turbinals is also the basis of their 
enormous heat-radiating power and their proportionate ability to 
pour out an abundance of watery vapor. In this manner the 
inspired air is furnished both with proper heat and moisture before 
entering the lower respiratory tract. In cases wherein, as a result 




MIDDLE 
MEATUS 



Key plate for Fig. 345. 

of pathological changes, these functions are restricted or destroyed, 
the mucosa of the lower respiratory tract, which does not possess 
these functions to any degree, becomes more or less irritated and 
the tendency to bronchial inflammation is increased. The average 
quantity of watery vapor thrown off each twenty-four hours has 
been estimated by Grayson at about 500 grams. 

The mucous membrane covering the nasal fossae is sometimes 
termed the Schneiderian or pituitary membrane. The nasal 
cavities and the accessory sinuses are lined by mucous membrane 
which is continuous with that of the pharynx, and even that of the 
nasolachrymal ducts and the lachrymal sacs. This fact partially 
explains the ease with which a purulent process may extend 
throughout this entire region, and often with disastrous results. 

The nasal mucous membrane has three layers, an upper 
epithelial layer in which the variety of epithelium differs according 
to the region, e.g.: In the olfactory or upper region a non-ciliated 
columnar variety is found, which contains the olfactory cells or 
nerve endings, and the mucous membrane is thinner. In the 
respiratory or lowest region the epithelium is of the ciliated or 



THE TURBINATE BONES. 



549 



columnar variety. Beneath the epithelial layer is a second layer or 
basement membrane, and a third layer made up of connective tissue 
varying' in thickness, which is composed of white elastic and fibrous 
elements, containing- the vascular, glandular, nerve and lymphatic 
structures. 

The lining of the nasal vestibule is cutaneous in character and 
its epithelium is of the squamous or flat pavement variety. The 
color of the mucous membrane is bright red or pink. 

DISEASES OF THE SUPERIOR AND MIDDLE TURBINALS. 

These are conveniently considered together on account of the 
peculiar structure of the region and because of the intimate relation 
of both turbinals with the ethmoidal cells. The chief clinical im- 
portance attaches to the middle turbinal, its anatomical relations 
and cell-like construction rendering it peculiarly liable to involve- 




Fig. 346. — Cystic middle turbinal with a large edematous polypus. 



ment in both general nasal and ethmoidal purulent processes. The 
space occupied by these turbinals is extremely limited; hence any 
pathological increase in size brings their outer surfaces into contact 
with the septum or the lateral nasal wall, separately or together, and 
produces nasal obstruction and pressure symptoms. 

The principal lesions in these bones, herein considered, are 
characterized by One common objective symptom, viz., enlargement. 
The lesions usually consist of cysts and bone abscesses, but occa- 
sionally cases of osteophytic osteitis and rarefying osteitis and 
neoplasms, either benign or malignant, are found. 

The anterior portion of the middle turbinal often consists of 
one or more large cells (Fig. 346). Opinions vary as to whether 
these cells are the result of pathological processes, anomalously 
located ethmoid cells or primary cysts (mucoceles). Turner, 
Harmer and others incline to the view that any one of these 
three causes may account for the condition. Often they increase 
during adult life, without pathological changes, but more commonly 
the increase is due to the extension of purulent processes from the 
ethmoidal cells, in which event they may assume the type of the 
pyocele or mucocele. 

The remaining pathological changes in the bone substance of 
the middle turbinals are periostitis and osteitis. Enlargement of 
the middle turbinal from osteitis is usually confined to its anterior 



550 NOSE AXD XASAL ACCESSORY SINUSES. 

end. The pathological change is gradual and is supposed to be the 
result of the irritating effects of dust and various other impurities 
which reach these tissues through the inspired air. 

Recurrent attacks of simple acute rhinitis, under certain con- 
ditions, are also believed to produce the same result. Of the 
pathological changes in the mucosa, simple edema and polypoid 
degeneration are the chief. 

In a considerable proportion of cases both the turbinal bone and 
its mucosa are the seat of pathological changes which require 
differentiation in the matter of diagnosis. When the bone alone is 
enlarged the mucosa is usually thin and appears as a firm covering 
with a smooth, regular surface which is hard and resistant. Certain 
other features are characteristic. When the mucosa participates 
in the diseased process, there is a purplish discoloration in hyper- 
plastic inflammations of the mucosa, an edematous or translucent 
appearance in mucoid hypertrophy (Fig. 428), and a rough, uneven 
surface covered with gelatinous-like masses in polypoid degenera- 
tion (Fig. 346). A variety of symptoms arise as the result of the 
last-named lesions of the middle or superior turbinals, some of which 
are necessarily reflex in character. 

The chief of these are: 1, symptoms referable to direct pres- 
sure upon the nerves ; 2, symptoms referable to obstruction of the 
drainage from the superior meatus, with or without occlusion of the 
orifices of the accessory sinuses (unilateral, sometimes bilateral), 
neuralgic headache, ocular symptoms ; 3, hay fever (see Chapter 
XXXII) ; 4, bronchial spasm (asthma) (see Chapter XXXII) ; 5, 
impairment of the sense of smell (anosmia). 

Treatment. — Any disease or abnormality of the middle turbinal 
should arouse a suspicion of accessory-sinus involvement. The 
pathological changes in the turbinals, above described, rarely occur 
primarily, but are of common occurrence in connection with 
ethmoidal, maxillary and frontal sinus infections. 

Cysts of the middle turbinal associated with ethmoidal-sinus 
disease should be surgically removed in a manner that will permit 
the surgeon to inspect the deeper structures with a view to the 
eradication of the underlying disease. 

Treatment of the Enlarged Middle Turbinal Bone. — Based 
upon the pathological changes it is obvious that local treatment and 
internal medication are effective only in cases of acute inflammation 
of the mucosa. Here the treatment is the same as that which has 
already been described as adaptable for simple acute rhinitis (see 
Chapter XXXIII). 

Surgical Treatment. — Enlarged middle turbinals, whether 
cystic or the result of periostitis or osteitis, should be subjected to 
operative measures: (a) When pressure symptoms are produced 
by the enlargement, (b) When the middle turbinal is the seat of 
extensive polypoid degeneration, (c) When the purulent process 
has invaded the cavity or cavities within the bone, (d) In cases 
where its removal is required as a preliminary step to the excava- 
tion of the ethmoidal cells, or for exploring of the fuontal sinus, 
sphenoidal sinus, or maxillary antrum. 



THE TURBINATE BONES. 



551 



Preparation of the Patient. — The nasal cavities should be thor- 
oughly cleansed of all secretions as a preliminary measure. Before 
proceeding to cleanse the cavities the long hairs in the nasal 
vestibule should be clipped away, both for purposes of cleanliness 
and to facilitate the inspection of the operative field. The nasal 




Fig. 347. — Angular flat applicator. The flattened out absorbent cotton, 
soaked with the anesthetic, has been laid upon it for the purpose of 
introducing it into the nares. 

cavities should then be thoroughly sprayed with normal physio- 
logical salt solution, and the external surface of the nose and lip 
should be thoroughly scrubbed with 1 : 5000 bichlorid of mercury 
solution. 

The Anesthetic. — The operation is preferably performed under 
local anesthesia, on account of the free hemorrhage which invariably 




Fig. 348. — Grunwald's 
punch forceps. 



attends the use of a general anesthetic and the consequent difficulty 
of obtaining at all times a good view of the operative field. When 
local anesthesia is employed the operation may be performed with 
the patient in the upright position, there is but slight hemorrhage, 
and the operative field is under constant observation, which insures 
both accuracy and rapidity. 

The induction of local anesthesia is accomplished as follows: 
(a) Spray the nasal mucosa with a solution of cocaine or alypin 2 
per cent, in adrenalin solution 1 : 5000, avoiding if possible the 



552 



NOSE AXD XASAL ACCESSORY SINUSES. 



entrance of the anesthetic into the pharynx, (b) After ten minutes 
apply flattened pledgets of absorbent cotton soaked in a 4 to 10 per 
cent, solution of cocaine in adrenalin 1 : 5000 to the middle turbinal 
bone. The pledgets are prepared and introduced as follows : A 
small flattened-out portion of absorbent cotton is placed upon the 
surgeon's forefinger and moistened with the anesthetic solution by 
means of an ordinary glass dropper. The pledget is then placed 
upon the angular flat applicator (Fig. 347), by means of which it is 
carried into the nasal cavity. The first pledget should be spread 
upon the septal surface of the middle turbinal ; the second between 
the middle turbinal and the lateral nasal wall, and the third is made 
to cover any remaining portions of the bone. The pledgets should 
remain in situ for at least a period of twenty minutes in order to 
insure complete anesthesia of the parts. 




Fig. 349. — The primary incision for the middle turbinotomy. 

The Operation. — Turbinotomy and turbinectomy are the terms 
wmich designate the operation by which a part or the whole of a 
turbinal bone is removed. The procedure, so far as it relates to the 
middle turbinal, as a rule is that of turbinotomy, whereby the 
anterior bulbous extremity of the bone is resected, although, when 
extensive disease of the anterior and posterior ethmoidal cells is 
present, it becomes necessary to remove the entire turbinal (turbi- 
nectomy). The operation should invariably be of sufficient extent 
to prevent future intranasal pressure, and to remove adjacent polypi 
and to enable the operator to approach the diseased ethmoidal cells 
or the sphenoidal cavity. 

The steps of the operation for the removal of the anterior 
bulbous extremity of the middle turbinal are as follows : — 

(a) Introduce a Griinwald punch forceps (Fig. 348) and clip 
about one-third of the anterior portion of the attachment of the bone 
(Fig. 349). The Holmes scissors (Fig. 350) are also adaptable for 
this purpose. 



THE TURBINATE BONES. 



553 



(b) The wire loop attached to a Krause snare (Fig. 351) is 
then introduced, allowing the distal portion of the loop to enter the 
primary incision and the heel to be pressed as far posteriorly as 
possible along the under surface of the bone (Fig. 352). In some 
instances better results are obtained by introducing the loop with 
its distal end upon the under surface and the tip of the cannula well 
pressed into the primary incision. 




Fig. 350. — The Holmes middle 
turbinal scissors. 



The operation may also be effectively performed by making 
the primary incision with angular clipping forceps, commencing at 
about the junction of the anterior and middle thirds of the bone 
and extending it in a perpendicular direction, after which the snare 
loop is introduced deeply into the incision and the bone cut away. 

(c) Upon the removal of the segment of bone after the manner 
above described (Fig. 353), all remaining polypoid masses, shreds of 




Fig. 351. — The Krause nasal snare. 



tissue and particles of diseased bone should be completely removed. 
For this purpose Briining's forceps (Fig. 401) is a most effective 
instrument, and its safety commends its use. By grasping the 
remaining shreds, polypi or segments of diseased bone, the instru- 
ment both breaks and pulls away the masses without danger of 
penetrating and thus injuring the deeper tissue-. 

The Removal of the Eniirc Middle Turbinal. — When it is neces- 
sary to remove the entire middle turbinal the same preliminary 
procedure (a) should be employed. The incision having been "made 



554 NOSE AND XASAL ACCESSORY SINUSES. 

a large snare loop is made to engage the entire bone and in this 
manner it is removed en masse. 

The primary incision is an important step in either operation, 
as it prevents the slipping of the wire loop. In many cases this 
bone may be removed with the clipping forceps alone, by extending 
the original incision entirely through until the desired portion has 
been completely separated from its attachment. The operation is 
usually free from pain, but as a rule the patients suffer slightly from 
surgical shock, and occasionally from the physiological effects of 
the anesthetic. 




Fig. 352. — The snare in position for severing the anterior portion 
of the middle turbinal. 

The surgical procedures required in extending the operation 
to the ethmoidal cells are fully described in Chapter XXXIX. 

Two methods of operating on the middle turbinal, which are 
described in the earlier text-books, namely, the use Qf the galvano- 
cautery and the electric trephine, are now obsolete, the former on 
account of its ineffectiveness, and the latter on account of the 
dangers attending its employment in this location. The hemor- 
rhage attending this operation rarely is excessive, and usually is 
controlled by pressure. Profuse hemorrhage during the operative 
procedure may be controlled by introducing a pledget of gauze 
saturated with a 1 : 5000 solution of adrenalin, to be left for a period 
of about five minutes. 

Upon completion of the operation the entire nasal cavity should 



THE TURBINATE BONES. 555 

be washed out with a normal salt or alkaline antiseptic solution. 
The denuded bone surface should then be covered (not packed) 
with a strip of sterile gauze saturated with a 12 per cent, solution 
of acetotartrate of aluminum, for the purpose of protection. This 
solution is both astringent and antiseptic; hence the gauze may 
safely be left in situ for from twenty-four to forty-eight hours. 
Furthermore, by its employment the dangers of postoperative 
hemorrhage are materially lessened. 

Upon removing the gauze the nasal cavity should again be 
cleansed in order to remove all retained secretions and blood-clots, 
and thereafter all dressings should be discarded. But daily cleans- 



1 Pi 




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in 1 


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fe-^JM 


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fB3r 




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Fig. 353. — The partial middle turbinal operation, with key plate. 



ing should be continued until healing is complete. Should there 
be a tendency to the formation of crusts, applications of weak 
benzoated or mentholated vaselin may be made over the entire 
surface. 

The Results. — The operation is followed by marked relief from 
hypersecretion and intranasal pressure, and nasal respiration is 
improved. When the turbinal enlargement is associated with 
ethmoiditis and the latter is simultaneously subjected to operative 
measures, the improvement both in local symptoms and in the gen- 
eral health is marked. Inasmuch as the overdistended ethmoidal 
cells, together with the enlarged turbinal, sometimes produce a 
widening of the nose and hence external deformity, the correction 
of the disease results in marked improvement in the facial expres- 
sion of the individual. 

For a consideration of nasal polypi the reader is referred to 
Chapter XLII, on New Growths, 



556 



XOSE AND NASAL ACCESSORY SINUSES. 



DISEASES AND DEFORMITIES OF THE 
INFERIOR TURBINALS. 

The pathological changes which develop in the tissues of the 
inferior turbinate are chiefly those which pertain to the mucosa 
underlying the soft tissues and will be considered under the 
headings: 1, acute inflammation (tumefaction, turgescence) ; 2, 
true hyperplasia; 3. atrophy. They are also subject to: 4, malfor- 
mations and deformities; 5, dilatations, and, 6, synechia;. 



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ostium //r\'--- MW, ^ 

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C^»k 




S>W\ 


Ar^ $> ^^^"*v 




# REMAINS OF^ /N^at; 


.^^^sP^C/ 


//miGOJ-E TURBINAI/ " 


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JIF 







Key plate for Fig. 353. 



1. Acute Inflammation. 

The pathological changes which accompany acute inflammation 
of the inferior turbinate consist of tumefaction or turgescence of 
the mucosa, which usually is intermittent and the result of engorge- 
ment of the venous sinuses in this mucosa. This condition usually 
is associated with a similar inflammatory process (acute rhinitis') 
which extends throughout the nasal mucosa, and whenever it per- 
sists the first step of chronic rhinitis has been reached. 

The inferior turbinal and its coverings are subject to all of 
the acute infections which invade the mucous membrane of the 
nasal cavities in general. These are fully described under their 
respective headings in Chapters XXIX, XXX, XXXI, and XXXII. 

The swollen tissue is soft and dimples when pressed upon with 
a probe, but the blood-vessels quickly refill upon the cessation of 
pressure. Extensive tumefaction of "the turbinal causes the latter 
to impinge upon the septum or upon the floor of the nostril and to 
obstruct or completely block the inferior meatus. These changes 
usually are bilateral. Upon the application of cocaine or adrenalin 
the tumefaction of the mucous membrane completely subsides. 



THE TURBINATE BONES. 



557 



2. True Hyperplasia. 

True hyperplasia of the inferior turbinal may occur in any 
portion of its mucosa, but is more common at the posterior extrem- 
ity, where it often reaches enormous size (Fig. 354). Extending 
backward into the postnasal space, these masses sometimes rest 
upon the upper surface of the palate, where they interfere with 
nasal respiration and with the ventilation of the middle ear. 

Hyperplasia of the inferior turbinal varies from a general 
thickening of the mucosa to the enormous cauliflower-like eleva- 
tions which project from sessile attachments to its surface. The 
latter are often confined to the posterior portion of the bone (Fig. 
355), but may extend throughout its entire surface. In one of the 




Fig. 354. — A large sessile hyperplasia (polypoid) removed from the 
posterior extremity of the inferior turbinal of an asthmatic. 



author's cases the entire inferior meatus from the vestibule was 
filled with this type of hyperplastic tissue, which was soft and 
polypoid in character, and extended into and filled a portion of the 
postnasal space. The entire mass was engaged in a wire loop and 
removed. 

Symptoms. — True hyperplasia of the inferior turbinal, espe- 
cially when associated with the deformities hereinafter described, 
results in sufficient enlargement to produce contact either with the 
septum or the meatal floor. Hence there is induced a serious dis- 
turbance of function on account of the resultant obstruction to nasal 
respiration and the free outflow of the secretions. Furthermore, the 
timbre of the voice may become impaired and distressing tinnitus 
and a sensation of fullness in the ears may ensue. The chief symp- 
tom, however, is obstruction, which may be unilateral, bilateral or 
alternating. In many cases the nasal obstruction increases on the 
side upon which the patient lies at night. It also is increased when 
the patient remains in imperfectly ventilated or superheated rooms. 
The advent of an attack of simple acute rhinitis induces the distress- 
ing symptoms which follow complete occlusion of the nares. In 



558 



XOSE AXD NASAL ACCESSORY SINUSES. 



some cases the pressure symptoms cause positive pain, which often 
is accompanied by nervous irritability and depression. 

Diagnosis. — Upon examination by anterior rhinoscopy any 
unusual enlargement of the inferior turbinal tissues should lead to 
a painstaking study as to the nature of the existing enlargement. 
The lower border of the inferior turbinal sometimes touches the 
floor of the nose and is surrounded by a mass of mucus, which often 
fills the surrounding spaces. This condition is usually indicative of 
true hyperplasia, but the latter may definitely be determined by 
applying a solution of cocaine. Turgescent tissue collapses under 
this drug, while true hyperplasia is but little affected when sub- 
jected to cocaine test. Contact of the inferior turbinal is usually 
visible, and the degree of pressure may be determined by probing. 




Fig. 355. — Bilateral posterior hyperplasia (cauliflower) 
of the inferior turbinate. 

Posterior hypertrophies are readily located by the aid of the 
postrhinoscopic mirror. It is not uncommon to discover posterior 
hypertrophies of the inferior turbinal of such enormous size that 
they conceal the posterior border of the septum by overlapping it. 
Furthermore, it is often possible to locate these growths by means 
of the finger-tip introduced into the nasopharynx. 



3. Atrophy. 

Atrophy of the inferior turbinal is usually confined to the soft 
tissues, although in some cases the bone itself becomes partially or 
wholly absorbed by the atrophic process. Atrophy of the inferior 
turbinal is invariably associated with a general atrophic process 
involving the intranasal structures, the symptoms and treatment of 
which are elsewhere described. (See Atrophic Rhinitis, Chapter 
XXXIV.) 



THE TURBINATE BONES. 559 



4. Malformations and Deformities. 

Malformations and deformities of the inferior turbinal are more 
common than is usually supposed. Under normal conditions the 
bone remains free from contact with the surrounding structures 
except at its point of attachment. Slight malformations may 
exist without serious results, but when the deformities are such as 
to cause impingement of the bone, either upon the septum, the 
nasal floor; or when the outer surface of the lower portion presses 
upon the lateral nasal wall, more or less annoying symptoms are 
produced. 

Malformations and deformities may exist without pathological 
changes in the soft tissues. The most common and controllable are 
those wherein the scroll-like conformation of the bone is incomplete, 
leaving its unattached edge widely separated from the body of the 
bone, and in contact either with the floor of the nostril or against 




Fig. 356. — The Jackson turbinotomy scissors. 

the septum. Occasionally the large^ whorl of the scroll extends 
unduly in a lateral direction andimpinges upon the lateral nasal 
wall. 

5. Dilatations. 

Sacculated enlargement is occasionally observed in the inferior 
turbinal. It is caused by a separation of the two osseous lamella? 
which comprise this bone. A prominent symptom of this condition 
is compression upon the lachrymal duct. It is important to differ- 
entiate a dilatation or sacculation from polypi or osteomata. 

Treatment. — (a) Local and internal, (b) Surgical. 

Both the local and internal measures required for the diseases 
of the inferior turbinals are similar to those already described in 
the chapters on Acute and Chronic Rhinitis. 

Indications for Operation. — Some form of operative interfer- 
ence is indicated whenever the hyperplasia or other disease or 
deformity of the inferior turbinals produces symptoms of obstruc- 
tion, intranasal pressure, altered secretion, interference with drain- 
age or with the normal function of the nose. 

Operative Treatment. —The operative treatment of hyperplasia, 
enlargement and deformity of the inferior turbinals may be defined 
under four general headings : — 

(a) Reduction of hyperplasia by means of the galvanocautery. 



560 NOSE AXD XASAL ACCESSORY SINUSES. 

(b) Reduction of hyperplasia with snare or scissors. 

(c) Turbinotomy. 

(d) Turbinectomy. 

General Remarks. — The nose should be prepared for the 
operation in the same manner as for operations upon the septum or 
middle turbinal. If the patient is a male who wears a mustache the 
latter should be covered with gauze, the ends of which are gathered 
and tied behind the patient's head. Likewise a sterile towel mav 
be applied over the forehead and hair. 

The Anesthetic. — Local anesthesia is preferable to general 




Fig. 357. — The snare in position for removing a posterior hyperplasia 
of the inferior turbinal. 

anesthesia in every particular for operations upon the inferior 
turbinal. The rules to be followed in applying the local anesthetic 
are similar to those heretofore outlined for operations upon the 
middle turbinals. 

It is sometimes difficult to introduce the thin pledget of gauze 
into the space between the turbinal and the lateral nasal wall, but 
this measure is important to secure complete anesthesia. 

The application of caustics and escharotics for the purpose of 
destroying hyperplasia of the inferior turbinal is a harmful and 
ineffective measure. They result in severe reaction, with painful 
and annoying symptoms which continue for several days, after 
which a large slough separates, leaving a foul granulating surface, 
and finally considerable scar tissue. 

(a) The Galvanocautery. — The galvanocautery has been widely 
used for the destruction of turbinal hyperplasia. It is applied 



THE TURBINATE BONES. 



561 



in the form of linear incisions, by puncture and subcutaneously. 
Applications of the galvanocautery by means of linear incisions, 
in order to be of lasting benefit, require deep insertions of the 
cautery knife and extensive searing of the tissues. A violent 
reaction follows and the resultant scar tissue is out of all proportion 
to the limited ultimate results. 




Fig. 3^8. — The Mial turbinal snare. 



It is possible to employ the galvanocautery submucously with- 
out wide destruction of the mucous surface. Fine platinum elon- 
gated points are employed, which are thrust deeply into the tissue, 
and the burning is thus chiefly confined to the submucous tissue. 
The author rarely employs the galvanocautery as a method for 
reducing inferior turbinal hypertrophies, believing that far better 




Fig. 359, 



-Partial (anterior) inferior turbinotomy by means 
of punch forceps. 



results are to be obtained by a clean-cut surgical removal of the 
tissue with scissors, knife or snare. 

(b) Reduction of Hyperplasia with Snare or Scissors. — For the 
removal of hyperplasia of the anterior extremity or inferior surface 
of the inferior turbinal, a preliminary linear incision is made with 
scissors, at a point which marks the boundary of the quantity of 
tissue which it is desired to remove, similar to Fig. 359, but not 
including the bone. The Jackson turbinotomy scissors (Fig. 3?^) 
are ideal for this purpose. The operation is completed by engaging 



562 NOSE AND XASAL ACCESSORY SINUSES. 

and removing the redundant tissue with a cold-wire snare. In some 
instances it is possible to remove the desired section of tissue with 
the scissors alone. 

For the removal of posterior hypertrophies the wire snare 
is the ideal instrument. A variety of snares have been devised 
for this purpose. As a rule it is possible to operate successfully 
with a simple straight snare (Fig. 357), by bending the loop slightly 
before its introduction into the nostril. An ingenious snare has 
been devised by Mial (Fig, 358) for the removal of posterior hyper- 
trophies. In intractable patients the technique is greatly facilitated 
by the aid of posterior rhinoscopy. The patient is instructed to 
depress his tongue ; the surgeon manipulates the snare with one 
hand and observes its movements in the mirror which is held in his 
other hand. In some cases the engagement of the wire loop over 




Fig. 360. — Partial (anterior) turbinotomy by tbe combined employment 
of tbe punch or scissors and the snare. 

the posterior tip is facilitated by passing the snare directly back- 
ward along the floor of the nose, and, when the end of the wire loop 
has reached the pharynx, the snare cannula is directed backward 
and slightly toward the median line of the pharynx till it too touches 
the postpharyngeal wall. This bends the wire loop at an angle 
toward the posterior tip of the inferior turbinal. The instrument is 
now slowly withdrawn until the loop encircles the hypertrophy; the 
snare is then gradually tightened until the wire loop slowly excises 
the diseased mass. While tightening the loop, the cannula must be 
gradually extended toward the growth ; otherwise the loop will slip 
away from its position around the tumor. 

(c) Turbinotomy. — The measures recommended for removing 
the anterior portion of the bone are three in number: 1. With 
scissors alone. 2. With punch forceps alone. 3. With scissors or 
punch forceps and snare combined. 

1. When the anterior end only is the cause of the obstruction 
it is possible by introducing the blades of the scissors, one upon 
the septal side and the other into the space between the turbinal and 



THE TURBINATE BONES. 563 

the lateral nasal wall, and by tilting the handles upward, to excise 
the desired section of the bone. 

2. The punch forceps (Fig-. 348) are most adaptable and effect- 
ive in the cases above described, on account of their small calibre 
and strength. The jaws of the instrument are applied to the bone in 
the lateral plane, or nearly so, and the primary cut (Fig. 359) is 
made. Without withdrawal the jaws are then reopened and inserted 
more deeply and thus the incision is extended until the resection is 
completed. 

3. The combined use of the scissors or punch forceps and the 
cold-wire snare possesses many advantages for the removal of the 
anterior end of the inferior turbinal. The operation was devised 
by Lake. 

The superiority of the punch forceps over the scissors is in its 
smaller dimensions, and the furrow which it cuts into the bone 




(Fig. 360) greatly facilitates the subsequent technique for adjusting 
the snare. 

After removing the section of bone, if the snare has failed to 
reach the limits of the obstruction, the remaining excess of bone 
can easily be clipped away with the punch forceps. 

Posterior inferior turbinotomy is rarely required, inasmuch as 
the enlargement is usually confined to the soft tissues (hyper- 
plasia). It is accomplished by means of the snare, in the manner 
described for posterior hyperplasias. 

(d) Turbine ctomy. — When the entire inferior turbinal is enor- 
mously enlarged, or in case its entire removal becomes imperative as 
a preliminary to other and more extensive operative measures, it 
should be cut away en masse. 

The operation is simple, and, barring occasional annoying 
hemorrhage, it is unattended by serious consequences. It is best 
performed by means of a succession of clips with the punch forceps 
(Fig. 348) carried through its line of attachment along the lateral 
nasal wall. 

The spokeshave (Fig. 3CA) and the large-sized Hallenger 
swivel knife (Fig. 327) arc also adaptable for this operation. 



564 



NOSE AXD NASAL ACCESSORY SINUSES. 



When the latter instruments are employed they are adjusted over 
the posterior end of the bone and drawn forward through its line of 
attachment to the lateral nasal wall. A small preliminary incision 
should be made through the anterior attachment of the bone, in 
order to prevent the tearing of the soft tissues as the instrument 
emerges. 

Submucous resection of the inferior turbinal, while feasible 
so far as the procedure is concerned, is applicable in but a limited 
proportion of cases, as any enlargement or deformity of the bone 
usually is accompanied by hyperplasia in its submucosa. 

After-treatment. — The after-treatment may be summed up in a 
few Avoids. For the control of persistent hemorrhage the patient 




ADHESIONS 

(SYNECMIAE) 



Fig. 362.— The various synechias (adhesions) which are observed 
in the nasal cavities. 



may be directed to spray the nostril with adrenalin solution 1 to 
5000. It is unnecessary to plug the nostril after an operation upon 
the inferior turbinal bone, except for the control of excess of 
hemorrhage, which is a rare occurrence. Tight plugging of the 
nares causes pain, sometimes produces sloughing, and favors 
infection. The denuded surface within the nostril may be protected 
by applying one or two layers of sterile gauze, moistened with a 
12 per cent, solution of acetotartrate of aluminum, to which may be 
added a few drops of a 1:5000 solution of adrenalin. The sterile 
gauze thus prepared produces no pressure or severe pain ; it is 
slightly astringent; it protects the wound from infection, and is an 
efficient safeguard against secondary hemorrhage. 

The after-treatment, further than this, is limited to the observa- 
tion of the ordinary rules of cleanliness. The inflammatory reaction 



THE TURBINATE BONES. 565 

is sufficient to cause considerable discomfort and to temporarily 
interfere with nasal respiration. This may be relieved by means of 
an occasional spray with a 1 : 5000 solution of adrenalin. After 
twenty-four hours the gauze should be removed, and thereafter the 
treatment should consist only of frequent cleansing with alkaline 
sprays. 

6. Synechias. 

Synechia? (Fig. 362) are quite common in the nares and are 
usually composed of adhesive bands, which unite the turbinal tissues 
with the septum. Occasionally the inferior and middle turbinals 
are so joined. They are rarely congenital, ■ and they usually result 
from traumatism. As a rule they are composed of connective tissue, 
but occasionally they consist of bone. Synechias occasionally 
extend from the lateral wall to either the inferior or middle turbinal 
bodies. Acquired connective-tissue synechias usually are the result 
of cicatrization of a nasal ulcer, bungling operative interference, or 
neglect of after-treatment following surgical operations upon the 
septum or turbinate bones. 

Treatment. — Synechias between the middle turbinal and the 
septum and those which join the inferior turbinal to the nasal sep- 
tum, the nasal floor or the middle turbinal (Fig. 362) should in- 
variably be resected. The operation is best performed by means of 
the punch forceps (Fig. 348) whenever the synechias can be reached 
with this instrument. Otherwise the band of tissue should be 
resected with scissors. By resecting a comparatively thick portion of 
the synechia, sufficient space is usually gained so- that re-formation is 
not likely to occur. In case recurrence becomes imminent, it is easily 
overcome by inserting a small section made up of several layers of 
rubber tissue between the opposing surfaces. This procedure should 
be repeated from time to time until the raw surfaces are permanently 
healed. It is obvious that in many of these cases the submucous opera- 
tion is indicated. 

New growths of the turbinals and nasal neuroses are respect- 
ively described in Chapters XLI, XLIL 



CHAPTER XXXVII. 
DISEASES OF THE NASAL ACCESSORY SINUSES. 

ANATOMICAL CLASSIFICATION. 

General Remarks. — A convenient grouping of the nasal acces- 
sory sinuses, based on the clinical phenomena, has been devised by 
Hajek, in which they are arranged into two series as follows: — 

Series I is composed of the maxillary, the anterior ethmoidal 
and the frontal sinuses. Series II comprises the posterior ethmoidal 
and the sphenoidal sinuses. 

The sinuses composing series 1, or the anterior group, drain 
into the middle meatus (beneath the middle turbinal). 

The sinuses which compose series II, or the posterior group, 
drain into the superior meatus (above the middle turbinal). 

The frontal sinus and occasionally one or two anterior eth- 
moidal (frontoethmoidal) cells communicate with and hence drain 
into the infundibulum. Drainage of the anterior ethmoidal cells 
and the maxillary sinus takes place directly into the hiatus semi- 
lunaris, with which they normally communicate. 

The posterior ethmoidal cells and the sphenoidal sinuses com- 
municate with and drain into the superior meatus. The outlets of 
the sinuses are by no means constant, and the details regarding such 
variations as occur are outlined in the surgical anatomy of the 
individual sinuses. The mode of drainage of an accessory sinus is 
direct when the ostium is in its floor; but, when the ostium of the 
sinus is high up and hence remote from its most dependent portion, 
drainage is effected only by means of the cilia of its epithelial lining. 

For example, the outlets of the frontal sinuses invariably are 
from their most dependent points; hence their secretions gravitate 
directly into the infundibulum. On the contrary the outlets of the 
maxillary and sphenoidal sinuses are located high up so that direct 
drainage is impossible and the secretions must be conveyed by the 
ciliated epithelium. The relatively small calibre of the outlets of 
the nasal accessory sinuses is an important clinical factor in the 
inflammatory processes which invade their lining mucous mem- 
branes. It is on account of the lack of adequate drainage and 
ventilation of the sinuses, owing to the restricted calibre of their 
openings, that the severity, pathological changes and limitations of 
these processes differ materially from like inflammations which 
attack the nasal mucosa proper. 

THE MAXILLARY SINUS (ANTRUM OF HIGHMORE). 

1. Anatomy. — The maxillary sinus or antrum of Highmore is 
situated in the body of the superior maxillary bone (Fig. 363). It 
is separated from the nasal cavity by the outer (lateral) nasal wall 
(566) 



DISEASES OF NASAL ACCESSORY SINUSES. 567 

(Fig. 364), with the exception of a small opening, the ostium 
maxillare, which is hereinafter described. 

In shape the antrum is a three-sided, irregular, inverted 
pyramid, the base being formed by the floor of the orbit, and its 
apex situated over the alveolar process. The roots of the first and 
second molar teeth sometimes protrude into the maxillary antrum. 
Some authors place the base of the antrum at the outer wall of the 
nasal chamber and the apex toward the malar process. The three 
sides of the pyramid are the facial, orbital and the nasal walls. It 
is of surgical importance to note that the walls of this sinus vary 
much in thickness. The thinnest portion is the nasoantral wall in 




Fig. 363. — Front view of a vertical coronal section of the skull on 
the plane of the second molar teeth, with key plate. 

the region of the ethmoid bone, from which at times it is only 
separated by a membrane. This fibrous membrane, known as the 
hiatus semilunaris, is situated between the bulla ethmoidalis and 
the processus uueiuatus ; the remaining portions of the inner wall are 
bony. The thickest wall is the temporal, outer or posterior wall, 
pointing toward the zygomatic fossa (Fig. 365), the upper posterior 
angle of which is in contact with the cranial cavity. 

The ostium maxillare (Fig. 363) is the natural opening of this 
sinus, through which it drains into the nasal cavity. It is situated 
in the lateral nasal wall, nearer the roof than the floor of the cavity, 
and opens into the middle meatus of the nose at the posterior 
extremity of the hiatus semilunaris. Hence this cavity depends for 
drainage upon the cilia of the epithelial lining. Sometimes one or 
more accessory openings are found. The mucoperiosteum lining 



568 



NOSE AND NASAL ACCESSORY SINUSES. 



the antral cavity is as a rule arranged in folds, and, rarely, the sinus 
is divided by septa into two or mure compartment-. 

The maxillary ostium (Fig. 364) being high up in the antrum, 
in the erect position of the body, secretion cannot gravitate into the 
nasal cavity unless the antrum is entirely filled (Hajek). This 
opening varies in size and shape ; it is usually circular or elliptical, 
but at times is a mere slit, its direction being downward, for- 
ward and outward, and. according to Zuckerkandl, it measures from 
3 to 19 mm. in its longitudinal diameter, and about 6 mm. in its 
transverse diameter. Its hidden position makes it difficult to insert 
a probe or cannula ; but accessory openings when present are more 
accessible. 




Key plate for Fig. 363. — 1, ethmoidal cells; 2, frontal sinus; 3, middle 
meatus; 4, maxillary antrum; 5, inferior turbinal ; 6, ostium maxillare ; 
7, inferior meatus. 

The apex of the antrum (according to our description) is 
important on account of its relation to the dental process, to 
diseases of the roots of the teeth, and because the alveolar process 
sometimes extends into its lumen. The depth of the alveolar proc- 
ess varies, this being due to the absorption of the spongy substances 
during the development of the antrum. When the bony walls of 
the cavity are compact and thick there has been little absorption and 
the cavity is relatively small ; with much absorption the size of 
the antral cavity increases and the thickness of the walls and floor 
decreases. The thicker the alveolar process, the greater the protec- 
tion against inflammatory inroads into the antrum from the alveolar 
contents. 

The anterior wall (Fig. 364) is comparatively thin, especially 
in the region of the canine fossa, and here a large opening into the 
antrum can easily and safely be made. Its superior boundary is 
formed by the infraorbital ridge, its inferior by the malar process, 



DISEASES OF NASAL ACCESSORY SINUSES. 569 

its outer lateral by the malar ridge, and its inner lateral by the free 
border of the nose. 

The roof of the antrum forms also the floor of the orbit 
(Fig. 365). These two laminae of bone separate for a small space in 
the middle portion in order to allow the passage of the infraorbital 
nerve, which passes anteroposteriorly and emerges from the infra- 
orbital foramen. This nerve is often injured during operations on 
the antrum. 

The maxillary antrum in the adult is the largest of the acces- 
sory cavities of the nose ; it exists at birth, but only reaches its full 




Fig. 364. — Dissection showing the antral surface of the nasoantral 
wall and ostium maxillare, with key plate. 

size at puberty. Its average capacity is about 14 to 15 c.c. Occa- 
sionally it is of small size, but rarely is absent. The size and 
conformation of the maxillary antrum may vary considerably. 
Dilatations in various directions are due to irregularity in bone 
absorption during the period of development. Strictures of the 
bony walls or narrowing of the lumen of the cavity may also exist 
and interfere with operative attempts to enter the antrum. Depres- 
sion of the facial wall has also been observed. When marked, such 
depressions render it impossible to reach the antrum through the 
alveolar process. Sometimes the antral floor is on a higher level 
than the nasal floor, and this may hinder entrance into the antrum 
through the inferior nasal meatus. Furthermore, operative efforts 
to enter the antrum may be frustrated by anomalies (if the lateral 
nasal wall, chiefly by an outward bulging which may reduce the 
size of the antral cavity considerably. Septa, either membranous 



570 



NOSE AND NASAL ACCESSORY SINUSES. 



or bony, may divide the cavity wholly or in part. Zuckerkandl has 
noted a vertical septum dividing the antrum into a posterior and 
anterior cavity, and Hajek has seen this posterior half infected and 
a purulent discharge issuing from the olfactory fissure. 

Horizontal septa have been found less frequently. The author 
has observed nooks and recesses formed by small ridges and septa 
and believes that these favor stagnation and the more rapid develop- 
ment of pyogenic membrane. 

The antrum is lined by an extremely delicate mucosa, a con- 
tinuation of the nasal mucous lining. Tt is composed of a super- 
ficial or epithelial layer (ciliated), a middle or glandular layer (race- 




ALVEOLAR 

PROCESS 



Key plate for Fig. 364. 

mose), and a deeper, denser spindle-celled or periosteal layer; these 
layers are not always entirely distinct. The blood-supply of the 
antrum is derived from the vessels of the nasal mucosa which pass 
through the ostium maxillare, and some collateral branches of the 
vessels of the lateral nasal wall which pass through the bone to the 
inner antral wall. 

The topographical anatomy of the maxillary as well as any of 
the other accessory nasal sinuses is best studied on the moist and 
dry sections of the head, since the irregularity in dimension and 
form of these cavities renders accurate description unsatisfactory 
and often misleadine. 



Diseases of the Antrum. 

Etiology and Pathology. — The antrum of Highmore is subject 
to acute and chronic inflammatory changes in its lining mucosa, 
hydrops, necrosis of its walls, cysts, and tumors (benign or malig- 



DISEASES OF NASAL ACCESSORY SINUSES. 



571 



nant). The inflammatory changes are acute or chronic catarrhal, 
and acute or chronic purulent (empyema). The inflammatory 
process within the maxillary sinus as a rule is an extension from 
some part of the nasal cavity or from a neighboring accessory sinus, 
and includes those which are directly due to the infectious diseases, 
as the exanthemata, influenza, diphtheria, tuberculosis, and syphilis. 
The protrusion of carious teeth into the lumen and unclean dental 
procedures are causes of infection of the antrum. Invasion of the 
bony walls of the antrum is due either to pathological processes, to 
traumatism or to tumors. 




Fig. 365. — The outer c 
antrui 



temporal wall of the maxillary 
with key plate. 



Zuckerkandl, who was the first to accurately describe the 
catarrhal form, contends that in acute attacks the secretion of mucus 
is at first slight and appears only after the hyperemia has existed 
for some time, that the mucosa of the antrum may gradually become 
infiltrated, swollen and edematous, and that the disease is usually 
transitory rind terminates in resolution. In a limited proportion of 
cases the disease becomes chronic, in which event the exudate takes 
place chiefly into the inner layer of the mucosa, while the deeper 
periosteal cells of the peripheral layer become edematous, and the 
whole membrane becomes thickened and often spotted with 
hydropic elevations. According to Domochowsky, this form of 
chronic catarrhal inflammation may become hypertrophic, or hyper- 
plastic, and transform the mucosa into a pale, hard membrane. The 
latter process may advance to almost complete obliteration of the 
antral cavity, or become arrested at anv stage of the transformation. 



572 NOSE \\l) NASAL ACCESSORY SINUSES. 

Acute Empyema of the Antrum. 

In acute empyema the mucosa of the antrum becomes hyper- 
emia edematous, showing localized hemorrhages into the tissues, 
and its surface usually is covered with pus. The pathological 
changes are more rapid and severe when retention (closed empy- 
ema) occurs. Some authors, among them Zuckerkandl, Hajek and 
Domochowsky, believe that the soft tissue is not swollen to the 
same extent in this condition as it is in the acute catarrhal form. 
Acute empyema usually terminates in resolution of the mucous 

LEFT FRONT* 
SINUS 




Key plate for Fig. 365. 

membrane, but, under unfavorable conditions, ulceration may occur 
and even extend to the bone and induce caries. Furthermore it may 
terminate in the chronic form of the disease. 

Chronic Empyema of the Antrum. 

The pathological changes primarily affect the mucosa as in the 
chronic catarrhal form. Later the mucosa gradually thickens — 
dependent somewhat upon the degree of retention — with prolifera- 
tion of the connective tissue and pus formation; at times the dis- 
charge is mucopurulent. Often the cavity is filled with polypoid 
masses. In the severe forms ulceration of the mucosa takes place, 
and, when the periosteal layer becomes involved, osteophytes and 
osteomata may develop. According to Hajek, inflammatory tumors, 
including cysts, polypi and hydrops of the antrum of Ilighmore, are 
probably the result of chronic inflammatory changes in the mucosa. 



DISEASES OF NASAL ACCESSORY SINUSES. 573 

The polypi are usually located in or about the ostium, and have 
either a pedunculated or a broad attachment. They are prone to 
protrude through the ostium into the nasal cavity. Chronic empy- 
ema sometimes results from severe or neglected attacks of acute 
empyema. 

Empyema of the antrum is usually unilateral. Occasionally it 
is bilateral, and, rarely, the entire accessory sinus system becomes 
involved (pansinusitis). 

Symptoms. — The chief symptoms of an empyema of the antrum 
are pain and the discharge of pus from the nose. Pain is more 
common and constant in acute empyema, and its severity is de- 
pendent upon the degree of retention of the secretions. Likewise 
retention (closed empyema) occurs more frequently in acute cases. 
Unless the retention is prolonged as a result of inflammatory thick- 
ening of the mucosa surrounding the ostium maxillare, or from 
protrusion of polypi, the pain gradually subsides. In recent cases 
with retention the pain is located chiefly about the eminence of the 
malar bone and in the infraorbital region of the affected side. The 
teetli of the upper jaw may be the seat of severe pain, and at the 
same time sensitive to touch. From these points the pain radiates 
to the orbit, the supraorbital region and toward the ear. 

Tenderness upon pressure or percussion is sometimes elicited 
over the malar process in its anterior portion, in the canine fossa, 
and in the infraorbital region. The pain, as a rule, is intermittent 
and neuralgic in character, and with the advent of free discharge 
it gradually subsides. In chronic empyema pain is less constant, 
except during exacerbations. Usually the sense of smell is 
impaired, and sometimes complete anosmia is complained of. A 
subjective malodor may be present, and occasionally there is nasal 
obstruction, epistaxis, and eczema in and around the nasal vesti- 
bule. Aprosexia, insomnia, and nervous depression or excitement 
are remote symptoms. In some cases fever, chills and gastric irri- 
tability are noted. Fever, however, is rare. 

During all stages of an empyema of the antrum a purulent 
secretion into the middle meatus, with inflammatory thickening or 
hyperplasia of the nasal mucosa, constitute the constant objective 
si^ns. External swelling, while not common, is usually confined to 
the tissues about the malar eminence. A characteristic of the puru- 
lent discharge is its profusion in the morning and its partial or com- 
plete cessation during the day. This is accounted for by the 
situation of the ostium ( Fig. 366), which impedes the escape of the 
secretion in the erect position of the body. The discharge is 
increased by recurrent colds to which patients with antral diseases 
are subject. In old eases the discharge is often fetid. In character 
it is mucopurulent or purulent, and in acute east's the color is some- 
times bright yelli »w. 

Diagnosis. — While the variability both of the subjective and 
objective symptoms makes the diagnosis at times difficult, the fol- 
lowing rules for guidance usually suffice to establish a diagnosis 
of empyema of the maxillary sinus: 1, the intermittence in the 



574 



NOSE AND NASAL ACCESSORY SINUSES. 



flow of the pus ; 2, lowering- the maxillary ostium by having the 
patient bend the head forward and toward the unaffected side 
(Frankel-and Ziem), or by the method of Bayer, who lays the 
patient on his abdomen and allows the head to hang over the edge 
of the bed, in order to effect more. rapid discharge of the secretion; 
3, flushing through the ostium or an accessor}' ostium (this is rarely 
possible); 4, exploratory puncture with subsequent Hushing or 




Fig. 366. — The location of the ostium maxillare and the exploratory- 
puncture of the maxillary antrum. 



aspiration (Fig. 366) ; 5, transillumination (Fig. 367) ; 6, radiographs 
of the head (Figs. 384 to 390) in the posteroanterior diameter give 
valuable diagnostic information, when properly interpreted. 

Patients with a history of unilateral or bilateral nasal discharge, 
especially when it has existed for some time, should be subjected to 
a careful examination of all the accessory sinuses. As a rule it is 
possible to eliminate one sinus after another until the disease is 
definitely located. At the first examination the secretion may not 
be visible, for the reason that the patient naturally frees the nose of 
the discharge by blowing just before entering the examination 
room. In this event he should be requested to desist from blowing 




Fig. 367. — Transillumination of the maxillary antra (antra of 
Highmorc). Right side healthy, as shown by bright illumination under- 
neath the orbit, and through the pupil. Left side diseased. 



DISEASES OF NASAL ACCESSORY SINUSES. 



575 



the nose for a short period of time, in order that a reaccumulation of 
secretion may take place. In empyema of the maxillary sinus the 
pus exudes into the middle meatus, flowing from about the centre 
of the under surface of the attachment of the middle turbinal toward 
the nasal floor, except in cases either of extreme atrophy or hyper- 
trophy, when the flow may take other directions. In the morning, 
if the patient has not cleansed the nasal cavity, upon posterior 
rhinoscopy considerable secretion will be found in the nasopharynx. 
Pain upon pressure over the antral wall, when present, is of diag- 
nostic significance. 

Aside from the characteristic pain and discharge, transillu- 
mination is the most valuable diagnostic aid, especially when the 
disease is unilateral. If transillumination (hereinafter described) 




Fig. 368. — The Coakley transillumination lamp. 



reveals a dark area over the malar eminence and beneath the orbit 
upon the side which has been the seat of the characteristic pain and 
discharge, in contradistinction to the bright glow portrayed by the 
malar eminence, infraorbital space and pupil upon the opposite side 
(Fig. 367), the diagnosis of empyema may be considered suffi- 
ciently positive to warrant an exploratory puncture (Fig. 366) for 
the purpose of evacuating the pent-up pus. 

The examination should be conducted as follows: — 

1. Make a preliminary rhinoscopic examination of the nasal 
cavities and note the condition .of the mucosa, the location and 
degree of inflammation and infiltration of the soft tissues. In acute 
maxillary sinusitis it is common to find the swelling so great as to 
produce complete occlusion of the affected side. Note the presence, 
location, character and quantity of the secretion. 

2. Spray the nostril of the affected side with a 2 per cent, solu- 
tion of cocaine, followed five minutes later with a spray of 1 : 5000 
solution of adrenalin. 

3. During the period required (fifteen or twenty minutes) for 
local anesthesia and shrinkage of the soft tissues to take place, the 



576 



NOSE AND NASAL ACCESSORY SINUSES. 



sinuses should be transilluminated, in the following manner: Place 
the patient in a totally dark room in which the transilluminating 
apparatus is located. The direct current, controlled by a proper 
rheostat (Fig. 3), is preferable to storage batteries. The original 
instrument devised by Herying for this purpose was uncouth, 
unwieldy and expensive. The author modified and simplified the 
apparatus, but at the present time the lamp devised by Coakley 
(Fig. 368) is in general use for transilluminating the maxillary 
antrum ( Fig. 367) and frontal sinus (Fig. 382). It is especially to 
be commended on account of the movable glass hood, which is 
easily sterilized. A good rheostat is necessary, and one which is 
suitable for the kind of current (alternating or direct) which is in 
use. 

Placing the glass-covered lamp into the mouth, with the lips 
closed, the light is turned on and the results noted. The lower part 
of the face is not to be considered in a diagnostic sense, inasmuch 




Fig. 369. — Mylcs's antrum trocar and cannula. 



as the cheeks show a glow of light up to the level of the antrum 
floor, even when the latter is the seat of disease. Normally there 
is a glow of light underneath the orbit, and usually a reflection 
through the pupil upon the healthy side, and darkness at the corre- 
sponding points upon the diseased side (Fig. 367). The degree of 
illumination depends both upon the thickness and density of the 
bones, and upon the candle power of the lamp. Should the patient 
wear any dental apparatus which might obstruct the light rays, it 
should be removed before attempting to transillumine the maxillary 
sinuses. 

In cases of bilateral empyema of the maxillary sinuses trans- 
illumination is of less value. Under these circumstances, if the 
transillumination is negative on both sides, then bilateral sinusitis 
may reasonably be suspected. 

4. Having completed and recorded the transillumination find- 
ings, a sufficient time has elapsed to obtain the full effect of the 
cocaine-adrenalin application. A flow of pus between the middle 
turbinal and the septum indicates disease of the posterior ethmoidal 
cells, or the sphenoid sinus, or both sinuses. 

If the pus is exuding from the space between the middle 
turbinal and the outer nasal wall, the disease is located in one or 
more of the sinuses which form the anterior group — the frontal, the 
anterior ethmoidal or the maxillary. 



DISEASES OF NASAL ACCESSORY SINUSES. 577 

Skiagraphs. — In skiagraphy we possess a valuable diagnostic 
measure, both in determining the size and shape of the accessory- 
sinuses and their diseases. - Skiagraphy is more fully described in the 
following chapter, on Diseases of the Frontal Sinuses. So far as the 
maxillary sinus is concerned the difference between the healthy and the 
diseased side is often well marked on the skiagraph (Fig. 384). Owing 
to the pathological changes in the diseased antrum in which the thick- 
ened lining membrane displaces the air, sometimes to complete rarifica- 
tion, the skiagraphic plate shows the diseased side with an ill-defined 
or blurred boundary, whereas the healthy antrum shows a well-defined 
boundary. The X-ray also gives fairly good results, even where the 
bone is greatly thickened. 

A marked improvement in the methods of non-operative treatment 
of purulent conditions of the nasal accessory sinuses has been achieved 
by the use of the suction pump apparatus devised by Dr. Lewis A. 
Coffin, of New York, and fully described in the Laryngoscope, Decem- 
ber, 1915, page 832 (Fig. 369a). By means of this, instrument, at- 
tached to an electric pump, a sufficient degree of negative pressure may 
be induced to draw the accumulation of pus from the sinuses into the 
nasal cavity, and often into the reception bottle itself. It has an added 
advantage that by means of the spray attachment a nebula of any 
type of remedial agent may be forced into the vacuumized cavities. 
The change in the nose from the positive to the negative pressure may 
thus be alternated as often as necessary. In the experience of the 
author much benefit may be expected from the employment of the 
suction apparatus in a large majority of cases of both acute and chronic 
purulent sinusitis. Among the remedial agents recommended are 5 
per cent, solution of carbolic acid and Churchill's tincture of iodine. 
Solutions of Bulgarian Bacilli have also been employed for the same 
purpose but the chief benefit seems to arise from the suction element 
in the treatment. 

Prognosis. — The prognosis in chronic suppuration of the antrum 
depends largely upon the factors which enter into its causation and the 
form of treatment instituted. In mild cases warm saline or antiseptic 
irrigation, through the natural opening where that is possible, or else 
through an artificial puncture through the nasoantral wall underneath 
the inferior turbinal ( Fig. 366), may effect a cure. When of dental 
origin the removal of the diseased tooth and irrigation through this 
opening will often cause an empyema to yield. Pyogenic or degenera- 
tive changes in the mucosa, causing polypoid or cyst formation, re- 
quire some form of surgical procedure (usually radical) to cure the 
disease. 

Treatment. — In the acute catarrhal inflammation of the antrum 
the nasal inflammatory condition must be treated the same as that 
described for acute rhinitis (Chapter XXXIII), and efforts made to 
facilitate drainage from the natural antral opening. For this purpose 
pledgets of absorbent cotton saturated with a 4 to 10 per cent, solution 
of cocaine or alvpin, combined with a 1 : 5000 solution of adrenalin 
chlorid. arc applied to the nasal cavity, in the region of the ostium 
maxillare, in order to contract the soft tissue and thus promote the 

37 



578 NOSE AXD NASAL ACCESSORY SINUSES. 

drainage of the antrum. Warm saline douches to the nasal cavity, re- 
peated at intervals of two or three hours, tend to allay the inflamma- 
tory process. Should these measures prove ineffectual in establishing 
free drainage, surgery must be resorted to. 

Drainage being more effective from the most dependent part of a 
cavity, an artificial opening should be sought as near the floor of the 
antrum as feasible (Fig. 366). For the purpose of irrigation the nasal 
route, hereinafter described, is preferable to openings made through 
the canine fossa or alveolar process. The extraction of a tooth to gain 
an entrance into the antrum the author condemns, unless a diseased 
tooth or necrosis of the alveolar process is responsible for the purulent 
condition. To enter through the alveolar process a drill is introduced 
through the root cavity of the second bicuspid or flrsi molar tooth; the 




Fig. 369a. — This instrument consists of two bottles mounted on the 
lower side of a tube one-half inch in diameter which terminates in an 
olive-pointed tip about three and one-half inches from the bottles. Be- 
tween the bottles is a switch key by means of which the inside -of either 
bottle may be connected with the lumen of the connecting tube, the inside 
of the other bottle being at the same time disconnected from the same. 
Between the bottles also is a small tube extending through the key sleeve 
for the attachment of rubber tubing which connects the apparatus with an 
exhaust pump. When the key is so turned as to connect the second bottle 
with the connecting tube one is able to create a vacuum in this bottle by 
working the exhaust pump. This bottle is five inches in length and one 
inch in diameter and is the vacuum bottle of the apparatus. This bottle 
connects with the nose by means of the olive point and when the naso- 
pharynx is closed off from the oropharynx the nasal chamber and any 
cavities connecting with it are partially vacuumized when such a condition 
exists in the bottle. The nasal chamber may be closed either by instructing 
the patient to say ka, ka, ka, or the ballooning of a small rubber bulb in 
the chona. 

direction is upward and slightly inward to avoid puncturing into the 
nose or cheek. This opening may then be enlarged by chisel or bone- 
cutting forceps to facilitate examination and treatment of the sinus. 
Curettage, irrigation and gauze packing are then employed. The treat- 
ment may require a few weeks, during which time the opening can be 



DISEASES OF NASAL ACCESSORY SINUSES. 



579 



covered by a dental plate. In irrigating by the intranasal route, 
after cleansing the nose by douche or spray, the inferior nasal 
meatus on the diseased side is thoroughly subjected to adrenalin 
and to cocaine anesthesia, especially in the space between the 
inferior turbinal and the lateral nasal wall, where the puncture is to 
be made. 

If the operation is chiefly exploratory, a Myles antrum trocar 
and cannula (Fig. 369) may be introduced, and the irrigation accom- 
plished by withdrawing the trocar and then attaching the Myles 
irrigating tube (Fig. 370) to the cannula. When it is known that 
daily irrigations will be required for some time, it is better to 




Fig. 370. — Myles' s antrum irrigation tube. 

punch out a small section of bone with the Myles -reverse chisel 
punch (Fig. 371), thus securing an opening of sufficient size to 
permit daily irrigation without repuncturing. 

The antrum is entered below the inferior turbinal bone, about 
one inch from the inferior border of the nostril. Here the antral 
wall is comparatively thin, and the lachrymal canal lying anterior to 
this point is not injured. The trocar is pointed to the junction of 
the inferior turbinal with the outer nasal wall, and enters the antrum 
under slight pressure, in an outward and upward direction. If the 
antrum is filled with secretion it will readily flow out of the cannula, 



■M* • 



Fig-. 371. — Myles's reversed antrum chisel punch. 



Upon bending the head of the patient forward and toward the 
healthy side. Otherwise the secretion follows the return flow when 
irrigated. 

Irrigation of the Antrum. — Having introduced the cannula with 
its rubber-tubing attachment, the head should be bent forward over 
a pus basin. Then with a large-sized piston syringe (Fig. 43) a 
warm solution (salt or antiseptic) is thrown into the sinus. A 
return How follows through the normal ostium, consisting of the 
solution intermingled with the retained secretions of the antrum. 
The syringing should be continued until the return flow runs clear. 
Before removing the cannula the residual fluid should be blown 
from the antrum, using the syringe minus solution for this purpose. 
The irrigations should be repeated daily until all symptoms .abate 



580 



NOSE AND NASAL ACCESSORY SINUSES. 



and the antrum becomes clear under the daily transillumination. If 
found necessary the trocar opening may be enlarged by means of a 
burr, or preferably with some form ui punch forceps. From time to 
time granulations forming about the opening may have to he cleared 
away by curetting. Laboratory examination of the antral secretion 
is advisable. 

The pain attending the daily treatment is slight, providing 
local anesthesia is introduced about the orifice of the antral open- 
ing. One disadvantage of an opening- through a tooth socket is the 
necessity of wearing a dental prothesis. Another disadvantage is 




Fig. 372. — a, the flap of mucous membrane detached from the lateral 
wall of the nasal chamber under the inferior turbinate; />, the remaining 
portion of the inferior turbinate after the removal of the anterior third; 
c, the approximate size of the opening into the antrum Highmori neces- 
sary to evacuate the products of chronic suppuration. (Harmon Smith, 
with permission.) 



that the opening through the canine fossa requires constant care to 
prevent infection from the mouth or by aspiration of the buccal 
secretion into the antral cavity. 

The above treatment is successful in the acute cases, and in the 
chronic cases which show no deep-seated pathologic lesions. 
While it is difficult, in a given case, to determine beforehand the 
exact condition of the sinus and the amount of benefit to he derived 
from the simpler treatment, nevertheless, a trial of these milder 
surgical procedures should be made before resorting to the more 
radical measures. In protracted cases of empyema with irreparable 



DISEASES OF NASAL ACCESSORY SINUSES. 



581 



changes in the mucosa, palliative treatment is sufficient, and some 
form of radical operation becomes necessary. 

Radical Operation. — Of the radical procedures the simplest is 
the removal of a section of the anteroinferior portion of the naso- 
antral wall, in order that permanent free drainage may thereby be 
secured. This operation is applicable to cases which have not 




Fig. 372a. — Gouge devised by Curtis for opening the nasoantral wall 



progressed to the excessive formation of polypi in the antral mucosa, 
or to necrosis of the bony walls. 

The steps of the operation are as follows: Under local anes- 
thesia the anterior third of the inferior turbinal is first removed 
(Fig. 372). The nasoantral wall is then punctured and the opening 
enlarged with 




punch forceps of 
various types 
(Figs. 348, 373, 
374) until a per- 
manent opening- 
of at least five- 
eighths inch in diameter has been made, 
through which considerable curetment 
is possible, and polypi may be grasped 
and withdrawn (Fig. 372). Curtis en- 
ters the antrum in this location by 
means of a gouge (Fig. 372a) con- 
structed with a curve which naturally 
adapts itself to the nasoan-tral wall. 
With care a flap of mucous membrane 
ma}^ first be detached from the lateral 
wall. 1 'aching of this wound is un- 
necessary and undesirable after two or 
three days, the purpose of this oper- 
ation being to effect a cure of the dis- 
ease by establishing free drainage. In 
the author's experience the results of 
this operation fully warrant its employ- 
ment in simple forms of chronic empyema of the antrum. 

Operation through the Canine Fossa. — The facial or anterior 
wall allows a large opening, and has, therefore, long been a favored 
location for entering the maxillary sinus, as it seems best adapted 
to the wide exposure of the antral cavity. This method was 
originally practised by Lamorier and after him by Desault; [Custer 
later improved the technique, and the resection is often referred to 
as the Desault-Kiister method. 



Fig. 373.— W 
Forward cutting 
forceps. 



582 NOSE AND NASAL ACCESSORY SINUSES. 

The operation should be performed under general anesthesia, 
but loeal anesthesia may be substituted if necessary. After thor- 
ough scrubbing of the face and cleansing of the teeth and buccal 
mucosa, a gauze sponge should be inserted between the molar 
teeth, the cheek and gums, to absorb the blood which otherwise 
would run into the throat. An incision is then made through the 
mucous membrane and periosteum, following a line one-fourth inch 
above the free border of the gum from the molar to the canine 
teeth. The mucosa and periosteum are then lifted from the facial 
wall of the antrum with a periosteal elevator, and retained by 
retractors. With a small chisel the opening is effected through 
the bony wall of the canine fossa. It is usually advisable to avoid 
wounding the underlying mucosa until a considerable portion of 




forceps. 



the bony wall has been removed. It is advisable to remove a large 
section of the anterior bony wall, both for the purpose of inspection 
and to enable the operator to freely remove all the diseased con- 
tents of the antrum. The further removal of the wall is best 
accomplished by rongeur forceps and strong curets. An incision 
may now be made through the antral membrane and the contents of 
the" cavity evacuated. The sponge of gauze should be frequently 
changed during the operation and the blood-clots and debris cleared 
away. 

Subsequent to the resection of the anterior wall the steps of 
the operation depend upon whether the entire mucous lining is to 
be removed. Many operators favor the removal of diseased mem- 
brane only; others prefer to eradicate the lining mucosa in its 
entirety and allow the cavity to granulate. 

Tlie author's experience leads him to favor a total eradication 
of the entire mucous lining, as he only resorts to this operation in 
the severest cases. 

With either a brilliant headlight (Fig. 5) or a small electric 
lamp the antrum may now be thoroughly illuminated and its cavity 



DISEASES OF NASAL ACCESSORY SINUSES. 583 

inspected, and under the guidance of the electric light the entire 
mucous lining and the pathologic antral contents are renroved, by 
means of curets (Fig. 375) and forceps (Fig. 401). 

Carefully performed, this operation is attended with few acci- 
dents and but little danger. In one of the author's cases the salivary 
duct (duct of Stenson) was injured, and later on much annoyance 
to the patient occurred from the excessive flow of saliva into the 
nasal cavity at meal hours. It finally became necessary to divert the 
mouth of the duct from the antral wound, and thus return the flow 
into the buccal cavity. 

Having cleared the antrum of its diseased contents, the cavity 
is flushed with a normal saline solution and carefully packed 
with strips of iodoform gauze. Likewise the external wound is 
tightly filled in order to prevent rapid contraction of the soft tissues. 
The original tampon should be allowed to remain undisturbed for 
about five days, unless the temperature rises or other untoward 



G— o~* o— ' 



\^-' 



Fig. 375. — Myles's malleable shank antrum curets. 

symptoms develop. More or less hemorrhage follows its removal. 
After the first dressing each packing should be allowed to remain 
one day, and should be sufficiently snug to prevent exuberant granu- 
lations. In from four to six weeks the cavity granulates and the 
external wound may be allowed to close. So long as any fistula 
remains, the patient should be instructed to introduce a pledget of 
gauze of sufficient size to cover its orifice whenever food is taken. 
Should proliferations of the mucosa or polypi spring up, either 
around the margin of the wound or in the region of the ostium 
maxillare, they should be removed with a snare or a sharp curet 
and the denuded area cauterized with trichloracetic acid. Necrotic 
changes in the bony walls never have been observed by the author, 
and but few have been reported in the literature. 

This method of operating lias been subjected to many modifica- 
tions, both as to the size of the external opening and the measures 
instituted for the treatment of the diseased mucosa. Of the varia- 
tions the most notable is the breaking down of the whole or part of 
the adjacent nasal wall after the Caldwell-Luc method, and sub- 
sequent treatment of the antrum through the nasal cavity, while the 
buccal opening is closed by sutures at the original operation. A 
counteropening into the nose is often of great service, especially 
when combined with frontal or ethmoidal ('iterations. Furthermore, 
many advantages arc obtained by the early closure of the buccal 
opening, particularly in relation to mastication, and the results, per- 



584 



NOSE AND NASAL ACCESSORY SINUSES. 



taming to the time required for final healing and to the cessation of 
discharge, favor the counteropening into the nose. 

The Caldwell-Luc Operation. — Both of these operators de- 
scrihed independently a similar procedure, Caldwell, in New York, 
in 1893, and Luc, in France, in 1897. In detail the operation con- 
sists in creating a counteropening into the antrum, through the 
outer nasal wall. After removing the anterior wall by entering 
through the canine fossa, and after removing the diseased lining 
membrane of the antrum, a plug of gauze is introduced into the 
nasopharynx, as described under the treatment of epistaxis (Chapter 
XL), to prevent the blood from trickling down the pharynx and 
into the lower respiratory tract. If the anterior third of the inferior 
turbinal has not previously been removed, it should now be done 




Fig. 376. — First step in the Jansen antrum operation. 



after the method described in Chapter XXXVI, Fig. 372. Through 
the area of the outer nasal wall thus exposed, we now gain entrance 
into the antrum. The opening is then enlarged by resecting with 
bone-cutting forceps (Figs. 348, 373 and 374), in order both to meet 
the demands for permanent free drainage and to overcome the tend- 
ency to contract during the after-treatment. During the intranasal 
manipulation the operator should carefully avoid injuries to the 
nasal septum. 

Having created an ample opening the antrum is now cleansed, 
and the cavity tightly packed with strips of gauze (selvage-edged 
preferred). The mucoperiosteal flap of the canine fossa-opening is 
placed in position, and sutured with catgut. The plug behind the 
teeth and the postnasal plug are now both removed. 

Jansen has devised a further modification of the radical opera- 
tion which obviates the necessity of a preliminary opening through 
the canine fossa. The steps are as follows : — 

1. Dilate the nostril widely. 

2. Make an incision, following the lme of juncture of the 



DISEASES OF NASAL ACCESSORY SINUSES. 



585 



skin and mucous membrane of the vestibule through the soft tissues 
to the angle formed by the nasal and canine walls of the antrum. 

3. Elevate the periosteum first toward the canine fossa, and 
afterward from the anterior portion of the nasoantral wall, but 
without penetrating the nostril proper or severing the inferior 
turbinal. Introduce the retractors (Fig. 376), one toward the canine 
fossa and the other along the nasoantral wall, and retract the wound 
widely. Then break through the angle above described, either with 
rongeur forceps or chisel, and gradually resect the bony walls in 
all directions until a large opening has been made (Fig. 377). 

4. Remove the pathological contents of the antrum and flush 
with saline solution. 

5. Finally, from the lower point of the primary incision, 




Fig. 377. — Second step (resection of bone) in the Jansen antrum operation. 

through the soft tissues extend a second incision backward along 
the nasal floor for the purpose of establishing a permanent com- 
munication between the antrum and the nasal cavity. The antral 
cavity is then packed with gauze. 

6. This operation can be performed under local anesthesia. 

The After-treatment. — Following the severe traumatism to 
which the antrum and the surrounding tissues are subjected, the 
cheek and lower eyelids may become swollen and edematous. 
This troublesome complication may be controlled by the continuous 
application of ice-cloths over the swollen areas for from twenty-four 
to thirty-six hours. 

The primary packing should remain undisturbed for about five 
days, after which the dressings should lie changed daily. At each 
dressing the antral cavity should be Hushed with lukewarm physio- 
logical salt solution. The gauze packing may lie dispensed with 
after the third week, providing the granulations are healthy. 

For the patient's comfort it is well to caution him to avoid 
masticating his food upon the side operated upon for the first few 



586 NOSE AND NASAL ACCESSORY SINUSES. 

days. The further after-treatment aims chiefly at cleanliness and 
drainage. Strong antiseptics tend to irritate the denuded surfaces, 
and are, therefore, contraindicated. 

The patient may he taught to flush his own antrum daily 
during the final stage of the treatment. As the secretion decreases 
the number of douches may be diminished, but it is advisable to 
continue at least one treatment each day until the discharge ceases. 

In cases where the radical operation has been performed with- 
out the removal of the lining mucosa, and the secretion proves 
rebellious to gauze packing or flushing, local applications of silver 
nitrate increasing from 2 to 10 per cent, or of argyrol 25 per cent, 
solution will often be found of great benefit. The same measures 
are advised for reducing exuberant granulations in the wound 
cavity or around the orifice. 

Cysts. — Cysts do not primarily spring from the antrum, but 
develop in the alveolar process of the superior maxillary bone, and 
either are closed or perforated by a dental root. Hence, they 
are commonly termed dentigerous cysts. They often proliferate 
toward and into the antrum, and may even push the antrum aside 
or project into the middle meatus of the nose. In one of the 
author's cases a large dental cyst was opened through the nasal 
floor. The cyst extended downward into the alveolar process and 
a counteropening was made in the mouth. These cysts contain a 
hydropic fluid when non-infected and cholesterin crystals may be 
found ; in infected cysts, however, the contents are mucopurulent 
in character, or else of a doughy or cheesy consistence. The occur- 
rence of cysts has been ascribed to the retention or malformation of 
teeth, or to the suppuration of dentoblasts. These cysts often 
attain a considerable size. 

Treatment. — Free evacuation through a large opening, irri- 
gation and gauze packing are sufficient to effect a cure. 

Osteomata. 

Osteomata of the antrum are rare. They spring from the 
periosteum and probably are of congenital origin. They are of 
slow growth and may attain considerable size without causing 
symptoms. When encroaching on the nasal cavity the usual symp- 
tom is that of obstruction, with difficult nasal respiration. They 
seldom cause pain, and in this differ from the malignant growths. 

Treatment. — The treatment is surgical (see New Growths of 
the Nose, Chapter XLII, for the treatment of osteomata of the 
antrum). 




378. — Orifices of the nasal accessory sinuses. (Dcaver, with permission.) 



Frontal sinus. 

Straw in infundibulum. 

Orifices of anterior ethmoidal 

cells. 
Bulla ethmoidalis. 
Orifices of posterior ethmoidal 

cells in superior meatus. 
Superior turbinal (cut ). 
Straw in orifice of ethmoidal 

cell. 
Sphenoidal cell. 
Diaphragma sellae. 
Cavum sella;. 



k, Middle turbinal (cut). 

/, Hiatus semilunaris. 

in, Straw in nasal duct. 

11, Additional orifice of antrum 

Highmore. 
o. Straw in orifice of antrum 

Hiffhmore. 
p, Middle turbinal (cut). 
q, Middle meatus, 
r, Inferior turbinal. 
.v, Inferior meatus. 
t, Orifice of Eustachian tube. 




,Wi& .vi-l •■■ 










Key plate for Fig. 378a. 




Fig. 378a. — The abnormally large right frontal sinus, minus septa, 
occupies the entire right, middle and the major portion of the left supra- 
orbital regions. The drawing represents the head tilted forward and 
downward. Note the extreme height of the sinus in the median portion 
and the anteroposterior depth over the right orbit. The inner wall on the 
left shelves forward and forms the roof of the small left sinus. The 
latter is more fully illustrated in the following cut, which represents 
another view of the same specimen. (From Dunning's collection.) 




leuiW» 



BUM 18/ ( /|| 

V 






V 



r> 



..y 













Key plate for Fig. 3786. 




Fig. 3786. — The same specimen viewed with the head tilted slightly 
hackward. The dip of the abnormally large right sinus into the supra- 
orbital space is shown, the bony wall having been cut away. Note the 
similar dip of the extremely small left sinus, which has been opened just 
above the supraorbital ridge. The left sinus is entirely within the confines 
of the frontal bone and opens directly into the nasal cavity. (From 
Dunning's collection.) 



CHAPTER XXXVIII. 

DISEASES OF THE NASAL ACCESSORY SINUSES. 

(Continued.') 



THE FRONTAL SINUSES. 

Surgical Anatomy. — The frontal sinuses belong to the anterior 
group of the accessory sinuses. They are two irregular and some- 
what pyramidal shaped cavities, located above the orbits and 
between the tables of the frontal bone, upon either side of the median 
line. The frontal sinuses are subject to wide variations, both in size 
and in conformation (Figs. 386 and 387). The sinus of one side 
often is much larger than the opposite (Fig. 378a) or there may be 
but a single sinus, and in rare instances they are absent altogether. 

The floor of the frontal sinus is formed mainly by the orbital 
plate. The balance lies posterior to the articulation of the frontal 
and nasal bones and the nasal process of the superior maxillary 
bone. The anterior wall is formed by the outer plate of the frontal 
bone, and the posterior wall by the inner plate of the frontal bone. 

The frontal sinuses are lined by a continuation of the mucous 
membrane of the nose, minus the erectile tissue, and each sinus 
communicates with the corresponding nasal fossa by means of a 
passage known as the infundibulum or nasofrontal duct, which 
serves both for drainage and aeration. The upper portion of the 
infundibulum occupies a portion of the nasal part of the sinus floor, 
its posterior wall forming at the same time the anterior wall of the 
anterior ethmoidal cell. Unlike the sphenoidal and the maxillary 
sinuses, the openings (ostii) of the frontal sinuses lie in their most 
dependent portions (Fig. 345) and thus favor spontaneous drainage 
of the secretions. The ostium of a frontal sinus is rarely more than 
3 mm. in diameter, and often it is less. From its commencement 
in the nose the nasofrontal duct passes upward, forward and very 
slightly outward. Hence a probe or cannula must be curved in con- 
formity with its course in order to enter the frontal sinus. 

The infundibulum terminates below in the hiatus semilunaris 
(Fig. ?i7^), which lies in the middle meatus, between the processus 
uncinatus and the bulla ethmoidalis. Occasionally this duct opens 
directly into the antrum of Highmorc or the bulla ethmoidalis. 

The frontal sinuses are separated by a thin septum of bone, 
which occasionally is incomplete. This septum may be straight or 
deviated, and is deeply placed behind the nasal process of the 
superior maxillary bone and near the inner wall of the orbit. The 
termination of the nasofrontal duct in the middle meatus is about 
on a level with the palpebral fissure. Intermcdiarv septa in one or 
1 otli sinuses are common. Zuckerkandl has described the condition 
known as "bulla frontalis" an encroachment upon the lumen of the 
frontal sinus by an ethmoidal cell. 

(587) 



588 NOSE AND NASAL ACCESSORY SINUSES. 

According to .Munis, frontal sinuses of large dimensions may 
measure 2 inches from sick- to side, 1 ' _• inches anteroposteriorly, 
and occupy a great part of the vertical portion of the frontal bone. 
When very small they may scarcely extend above the nasal process. 
In elderly people the sinuses tend* to enlarge as a result of senile 
bone atrophy. 

The frontal sinuses are absent before the seventh year, and 
they develop from a gradual extension or pushing upward of the 
hiatus semilunaris. With the progressive separation of the two 
tables of the frontal bone, the sinuses continue to enlarge until 
about the age of twenty. The variations in size, shape and position 
may lie accounted for by this peculiar method of development. The 
anterior wall is comparatively thick, and in proportion to the size of 
the -hull the sinuses are larger in men than in women. The bony 
walls are thinner in women than in men, and they may become 
extremely thin in old persons of either sex. The floor or pars 
orbitalis is the thinnest of the frontal sinus walls, while the anterior 
wall is the thickest. 



DISEASES OF THE FRONTAL SINUSES. 

Diseases of the frontal sinuses occur for the most part in con- 
nection with or as a result of inflammatory affections which have 
primarily attacked the nasal cavities. Rarely the frontal sinus may 
be primarily diseased. On account of their late development, dis- 
eases of these sinuses are uncommon under the twentieth year. 
The frontal sinus diseases herein described are classified as fol- 
lows: 1, simple catarrhal inflammation; 2, purulent inflammation; 
empyema ; 3, periostitis and necrosis. Cysts and mucocele are 
pathologic conditions rarely found in the frontal sinus. Osteomata 
and malignant neoplasms at times encroach upon the frontal 
sinuses, but as a rule thev originate elsewdtere. 



Simple Catarrhal Inflammation. 

Simple catarrhal inflammation usually occurs in connection 
witli acute rhinitis, or "cold in the head." 

Etiology. — Etiologically, simple catarrhal inflammation of the 
frontal sinuses is a progressive inflammatory condition which 
occurs in conjunction with acute rhinitis. It extends by continuity 
from the nasal mucous membrane to that of the sinus, and partakes 
of the characteristics of the intranasal inflammatory process. 
Hence the etiologv corresponds with that of acute rhinitis (see 
Chapter XXXIII). 

Symptoms. — It is comparatively a common affection, and in 
the milder forms is characterized by localized frontal headache, 
sensations of pressure in the frontal region and about the eyes. 
These phenomena are usually intermittent, and may be renewed 
with each attack of acute rhinitis. In the severe forms, especially 
when accompanied with temporary occlusion of the nasofrontal 



THE FRONTAL SINUSES. 589 

duct, these symptoms become more severe and continuous. Pres- 
sure on the supraorbital plate or percussion over the sinuses during 
the early stages elicits considerable tenderness or pain. The inter- 
ference with the air pressure within the sinus aggravates the symp- 
toms and modifies the resonance (timbre) of the voice. Retained 
secretions, even in the catarrhal form, give rise to pressure and 
hence to severe, intermittent pain. 

Diagnosis. — The diagnosis is based upon the nature of the 
intranasal inflammation, and the characteristic symptoms. 

Prognosis. — The prognosis is good, barring the possibility of 
the inflammation assuming- a purulent type. All symptoms usually 
subside in from two to three days. 

Treatment. — The main indication for treatment is the relief of 
pain, and the maintenance of drainage through the nasofrontal duct. 
The cleansing and soothing measures outlined for acute rhinitis 
should form a part of the treatment of this affection. During the 
early stage considerable relief is obtained by the application of 
small icebags to the frontal region. If the icebag is not well 
borne, hot fomentations may give greater comfort. When the 
nasofrontal duct is obstructed as a result of the inflammatory proc- 
ess or from septal deflection, nasal polypi, or enlargement of the 
middle turbinal, the swelling and turgescence should be temporarily 
reduced by applications of suprarenal extract in the region of the 
infundibulum, thereby maintaining drainage of the pent-up secre- 
tions. 

The disease subsides rapidly, providing ample drainage is main- 
tained. It is inadvisable to attempt to wash out the frontal sinus 
by introducing a cannula, except when pus is present. 

Purulent Inflammation of the Frontal Sinus (Empyema, 
Acute and Chronic). 

The purulent form of frontal sinusitis, whether acute or 
chronic, is relatively rare, probably on account of the free drainage 
afforded by the favorably located and directed nasofrontal duct 
(Fig. 378). The acute form of the disease is more common than 
the chronic. 

Etiology. — Purulent invasion of the frontal sinus does not 
occur primarily except in rare instances, as the result of external 
traumatism of the frontal bone, or by intranasal operative inter- 
ference, which arouses the latent bacterial contents of the sinus to 
activity. The source of this affection is almost invariably found 
in some morbid process, either within the nasal passages or in the 
remaining accessory cavities, which lias extended by continuity to 
the mucosa of the frontal sinus. Traumatic ulcerations of the nasal 
mucosa, Foreign bodies in the nose, including maggots, centipedes 
and other insects, occlusion of the nasofrontal duct, either from 
tumors, polypi, septal deflections or enlarged turbinals, are among 
the causative Factors "I' a more 01 less mechanical nature. Further- 
more, acute or chronic purulent inflammation of the ethmoidal 



590 NOSE AND XASAL ACCESSORY SINUSES. 

labyrinth, sphenoidal sinus or the maxillary antrum often precedes 
the invasion of the frontal sinus. Of these, purulent ethmoiditis 
is the most prolific source of frontal sinusitis, especially in its 
chronic form. Acute attacks of purulent frontal sinusitis often 
arise from specific infections which have primarily invaded the 
nasal mucosa. Of these, la grippe and the exanthemata are types. 
Similarly, but less rapidly, tuberculosis, syphilis, ozena, and even 
neglected chronic rhinitis may extend to the frontal sinus. In 
any event, barring traumatism, the pathway of infection must he 
through the nasofrontal duct, and, so long as an infective or purulent 
process of any kind continues within the confines of the nasal cavi- 
ties, the frontal sinuses may become infected. 

Pathology. — Hie pathologic changes in acute frontal sinusitis 
are chiefly confined to the lining mucosa, which becomes inflamed, 
swollen and edematous. In severe cases, where the sinus is 
temporarily closed (closed empyema), localized hemorrhage into 
the tissue occurs, and pus fills the cavity. 

In chronic empyema the inflammatory stage is followed by 
thickening of the mucosa and proliferations of connective tissue, 
with a continuation of the pus exudate. Polypoid degeneration 
of the lining mucosa is less common in the frontal than in the 
maxillary sinus. In the severer forms ulceration of the mucosa, 
periostitis, and even necrosis of the bony walls may ensue. 

Symptoms. — During the acute stages of an attack the chief 
symptoms of empyema of the frontal sinus are pain and the dis- 
charge of pus. Pain, however, is the predominating symptom, and 
even in the chronic cases it is present, caused by the pressure of the 
pent-up pus. The pain varies in intensity from the severe, radiat- 
ing, lancinating type to that of the dull, pressure-like sensation 
known as "brow ague." It is located chiefly in the supraorbital 
region, the forehead and the top of the head, and is limited to one 
side. It is often of a neuralgic character, and is usually worse upon 
arising in the morning. As the day advances it gradually disap- 
pears and the patient is comparatively free from pain the latter part 
of the day and during the night. This Hajek explains upon 
mechanical grounds ; the lying position of the patient in sleep brings 
the natural exit for the secretions on a higher level and so causes 
pus retention. In the erect position drainage from the frontal sinus 
is favored and the pus slowly finds an exit into the middle meatus 
through the natural channel, with abatement of the frontal pain and 
headache. 

The eyeballs occasionally become tender and painful. Tender- 
ness either upon pressure or percussion upon the anterior wall, and 
more so upon the supraorbital plate, is a common symptom. In 
making pressure upon the supraorbital plate the thumb should be 
inserted deeply. This symptom is occasionally accompanied by 
nausea and vomiting. The flow of pus is usually yellowish at first ; 
later it becomes lighter in color. It is generally constant unless the 
nasofrontal duct is temporarily occluded, and it is often extremely 
offensive. Increased nasal secretion, purulent or mucopurulent, is 



THE FRONTAL SINUSES. 



591 



observed in all cases. Aprosexia, anosmia, eczema of the nasal 
vestibule and occlusion are other discomforts complained of by 
these patients. Orbital cellulitis is sometimes seen, and rarely 
periosteal abscess and perforation of the sinus wall. Whenever the 
nasofrontal duct remains occluded for a considerable period, an 
accumulation of pus results, which induces pressure symptoms, the 
chief of which are pain, erosions of the lining mucosa, necrosis of 
the sinus walls, or external deformity, often with more or less dis- 
placement of the eyeball. The latter symptom may be accompanied 
with diplopia or amaurosis. 

In the cases where the severity of the infection or continuance 
of pressure gives rise to erosions, ulcerations or necrosis of the 




Heath's frontal sinus probe. 



walls, an extensive infection usually ensues. The perforations 
occur through the anterior or outer wall, through the pars orbitalis 
or through the floor of the sinus, thus producing troublesome 
external discharge and considerable external deformity, including 
orbital cellulitis and displacement of the eyeball, with or without 
diplopia or amaurosis. But far more serious consequences arise 
when the posterior wall is the seat of a necrotic lesion, which 
permits an invasion of infection into the cranial cavity, with a sub- 
sequent development of purulent meningitis or brain abscess. 

The examination of the nares is conducted in precisely the 
same manner as for disease of the maxillary antrum (see Chapter 



Fig. 380. — Killian's frontal sinus cannula. 



XXXVII), and it is often necessary to eliminate the anterior 
ethmoidal cells by operation in order to determine fully whether the 
frontal sinus is the seat of disease. 

Diagnosis. — The history of the case furnishes important data 
upon which to base a diagnosis of empyema of the frontal sinus. 
Thus the characteristic supraorbital, frontal and parietal pain, the 
flow of pus into the middle meatus of the nose, the tenderness on 
pressure and percussion over the supraorbital and frontal walls, 
.'ind the external deformity when present, furnish presumptive evi- 
dence of frontal sinus disease, especially in cases wherein disease of 
the ethmoidal and maxillary sinuses can be excluded. The demon- 
stration of maggots within the nasal cavities should always direct 
the observer's attention to the Frontal sinuses. Tn a limited propor- 
tion of cases it is possible to insert a bent probe (Fig. 379) into the 
frontal sinus through the nasofrontal duct and observe a pus flow 



592 



NOSE AND NASAL ACCESSORY SINUSES. 



upon its withdrawal, or to introduce a cannula (Fig. 380) and wash 
out the secretion ( Fig. 381). The latter procedure is greatly facili- 
tated by a preliminary removal of the anterior third of the middle 
turbinal and the anterior ethmoidal cells. A diagnosis should never 
be based on pain over the frontal alone, inasmuch as this symptom 
so frequently accompanies affections of the sphenoidal and eth- 
moidal cavities that it is not characteristic for any of the conditions. 
Transillumination (Fig. 382) is less satisfactory in determining 
disease of the frontal sinus than of the maxillary antrum, inasmuch 
as tTiese sinuses arc so often unequally developed, varying in size 




Fig. 381.— Intranasal drainage of the frontal sinus. From retouched 
negative showing drainage tube in position in the left frontal sinus, and 
cannula in position in the right frontal sinus. (Ingals, with permission.) 

and conformity. Thus a dark area upon the affected side may indi- 
cate either the presence of secretion in the sinus, or an extremely 
small sinus may account for the phenomena. If possible the trans- 
illumination should be supplemented by a skiagraph. 

Skiagraphy of the Accessory Sinuses of the Nose. — Skiagraphy 
of the accessory sinuses of the nose was first advocated by Killian, 
but it has been perfected in America, mechanically by Caldwell and 
clinically by Coakley. 

According to Caldwell, 1 radiographs of the nasal accessory 

1 "Skiagraphy of the Sinuses of the Nose." American Quarterly Roent- 
genology, January, 1907. "Further Observations on the Roentgen-ray Ex- 
amination of the Accessory Nasal Sinuses," Transactions of the American 
Laryngological, Rhinological and Otological Society, 1908. 




Fig. 382. — Transillumination of the right frontal sinus. 



'THE FRONTAL SINUSES. 



593 




Fig. 383. — Two photographs of a model constructed for showing the 
effects of changing the position of the tube with reference to the skull. 
The direction of the rays in mesial plane is shown by stretched elastic 
cords passing from a point representing the target of tube to a bar 
placed in front of face and representing a line in the middle of plate. 
The principal ray is represented by a cord of lighter color than the 
others, and the basal plane is shown by a strip of tape fastened to the 
skull at its base. In .-/, the principal angle is approximately 25°, and it 
will be seen that the rays passing through frontal sinus are not obstructed 
by irregular parts of the base of skull. In B, the principal angle is too 
small (about 5°). In this position the shadows of parts of base of skull 
would be superimposed upon those of the sinuses. (Caldwell, with permis- 
sion.) 



594 NOSE AND NASAL ACCESSORY SINUSES. 

sinuses require accurate calculations of the measurements of the 
skull, the best appliances obtainable, and especially to have tubes of 
high penetration (about nine or ten of the Benoist scale). 

The plates should be correspondingly "fast," inasmuch as under 
the most favorable circumstances the tubes must be subjected to 
great strain in order to produce a good skiagraph of the accessory 
sinuses. 

Furthermore every minute detail regarding technique must be 
observed — the angle of direction of the rays, the position of the 
head, the distance of the target of the tube from the head, and the 
length of the exposure are among the more important requirements. 

Finally, the safety of the patient must be considered. He 
recommends that the target of the tube be placed at a distance of 
about 18 inches from the patient's head, and about twenty seconds 
as the usual time of exposure for the anteroposterior projection, and 
about ten seconds for the transverse projection. In the accom- 
panying illustration (Fig. 383) both a correct and incorrect angle 
of projection are shown. The chief purpose of the transverse pro- 
jection (Fig. 387) is to portray the depth of the frontal sinus for 
surgical purposes, but it often aids in interpreting the antero- 
posterior projection. 

He deprecates the employment of the terms "X-ray photo- 
graph," inasmuch as the skiagraph projections do not portray an 
object as the eye would see it, and at best is but a composite shadow 
of the objects which intervene between the source of the rays and 
the photographic plate. 

From the above comments it becomes apparent that Roentgen- 
ray specialists only are capable of producing reliable skiagraphs of 
the nasal accessory sinuses. From a pathological standpoint the 
skiagraphic plates are interpreted as follows : Upon examining a 
negative the outline of a healthy sinus is distinct, clearly defined, 
its septa are visible and its entire area is dark. In contradistinction 
the outlines of a diseased sinus are ill-defined, with a light, shaded 
cloudy area. Photographic prints do not reveal the full details 
which are protrayed in the original negatives. By placing the 
negative in a shadow box in a dark room the details are best 
revealed. 

A good skiagraph of the frontal sinuses, the ethmoidal laby- 
rinths and the maxillary sinuses is of inestimable diagnostic value. 
The skiagraph serves a double purpose, particularly in the frontal 
sinuses, inasmuch as the anteroposterior projection determines the 
probable pathological condition (Fig. 384) and the height, breadth 
and comparative size of both cavities and their septa (Fig. 385), 
while the lateral projection outlines their depth and height. Thus 
in Fig. 386 asymmetrical frontal sinuses are shown. In Fig. 3S>7, a 
lateral view, the depth of the frontal sinus is plainly seen. Small 
asymmetrical frontal sinuses are shown in Fig. 388. In Fig. 389 the 
skiagraph shows an absence of both frontal sinuses. Fig. 390 
illustrates slightly asymmetrical frontal sinuses, and the left frontal 
sinus, maxillary antrum and ethmoidal cells contain fluid. 




; M 





Fig. 384. — The cloudy appearance shown in right frontal sinus, eth- 
moidal cells and maxillary antrum indicates empyema of these cavities. In 
contradistinction the clearness of the opposite sinuses indicates the healthy 
condition of these cavities. (From collection of the Manhattan Eye, 
Ear and Throat Hospital.) 




Fig. 385. — The skiagraph shows nearly symmetrical frontal sinuses 
containing numerous septa. (From collection of the Manhattan Eye, 
Ear and Throat Hospital.) 



Fig. 386. — The skiagraph shows a very large right and small left 
frontal sinus, both containing septa. (From collection of the Manhattan 
Eye, Ear and Throat Hospital.) 




Fig. 387.— Lateral projection, showing the depth of the frontal sinuses. 
(From the author's collection.) 










Fig. 388.— The skiagraph shows small asymmetrical frontal sinuses. (F 
collection of the Manhattan Eye, Ear and Throat Hospital.) 




Fig. 389. — Total absence of the frontal sinuses. (From collection 
of the Manhattan Eye. Ear and Throat Hospital.) 




Fig. 390.— The skiagraph shows slightly 
empyema of the left Frontal sinus, ethmoidal 
(From collection of the Manhattan Fax-, Kar 



iymmetrical sinuses with 
Is and maxillary antrum. 
.1 Throat Hospital.") 



THE FRONTAL SINUSES. 595 

Treatment. — The treatment will be considered later, in conjunc- 
tion with that of the third or necrotic form. 

Periostitis and Necrosis. 

While a periostitis of the frontal sinus usually is due to trau- 
matism, necrosis of the frontal sinus walls may result either from 
traumatism or from extension of the pathological process from 
within. In rare instances a traumatism may induce a periostitis of 
the sinus walls which eventuates in necrosis. Syphilitic, tubercu- 
lous and diabetic subjects are more liable to necrosis. 

Prolonged pressure from retention of the secretions as a result 
of occlusion of the ostium is a common cause of necrosis of the 
sinus walls. Necrosis involving the anterior wall, the orbital plate 
or floor, or some portion of the nasofrontal' duct produces external 
swelling, periostitis, and eventually the formation of a fistula, which 
provides a means for the escape of the retained pus. Should the 
pressure be sufficient to displace the posterior wall of the sinus, 
obscure cerebral symptoms of meningitis or brain abscess ensue. 

Diagnosis. — In the earlier stages the diagnosis may be some- 
what delayed on account of the difficulties encountered in probing 
the interior of the cavity. After an external fistula has formed, 
simple probing will suffice to detect necrotic bone areas. 

Prognosis. — AA'hile the mild attacks of frontal sinusitis, tend to 
spontaneous resolution, especially when given the benefit of proper 
local medication, the more severe types are prone to persist indefi- 
nitely unless terminated by operative procedures. 

The necrotic variety, especially when involving the posterior 
wall of the sinus, is grave and often terminates fatally. 

Treatment. — (a) Of acute purulent frontal sinusitis. The 
measures heretofore advised for the treatment of the catarrhal form 
of the affection should be employed during the early stages of 
acute purulent frontal sinusitis, and such internal medication pre- 
scribed as the individual case may require for the relief of the 
underlying inflammatory process. A large proportion of all acute 
cases require no further treatment and recover in from two to seven 
days. These favorable results ensue generally in cases where drain- 
age is not impeded by obstruction of the nasofrontal duct. Further- 
more it is possible to effect a final cure, even when drainage 
temporarily is obtainable only by the employment of sprays and 
applications of adrenalin and cocaine. 

When the pain is severe it becomes imperative to give tem- 
porary relief by administering opiates. Whenever these measures 
fail to relieve the pain and terminate the discharge, other pro- 
cedures must be employed for the purpose of procuring more satis- 
factory drainage. If it is possible to insert a cannula into the naso- 
frontal duct, the sinus should be irrigated. The douching of the 
sinus may serve a double purpose, thai of irrigation and antiphlo- 
gistic treatment. For simple irrigation warm physiological saline 
solution, approximately 1 dram of sail in a pint of warm water, is 



596 NOSE AND NASAL ACCESSORY SINUSES. 

sufficient. After applying cocaine and adrenalin to the tissues 
surrounding the ostium, the frontal sinus cannula should be 
introduced (Fig. 381). The solution is gently forced into the 
sinus by means of a piston syringe. Previous to irrigating the 
sinus all retained secretions should be removed from the nasal 
cavity. A reappearance of pus immediately after irrigation of the 
sinus is abundant evidence that the douching has been effective. 
The entrance of fluid into the frontal sinus produces an immediate 
sensation of fullness and pain in the supraorbital region. The 
return flow is immediate unless the cannula completely blocks the 
lumen of the duct, in which event the contents of the sinus may be 
withdrawn through the cannula, by means of suction. 

Irrigation of the sinus is usually followed by a copious dis- 
charge of pus, mixed with the remains of the solution which has 
been employed', and it is epiite common for comparatively severe 
attacks to subside under this form of treatment. Furthermore 
intelligent patients often are able to acquire the necessary skill to 
pass the cannula and irrigate their own sinuses. 

Unfortunately, in many patients who suffer from acute 
empyema of the frontal sinus it is impossible to insert a probe or 
cannula on account of obstructions in the form of enlargement of the 
anterior end of the middle turbinal, swollen and edematous nasal 
mucosa, polypi which surround and block the nasofrontal duct, or 
an unusually large India ethmoidalis. Under these circumstances 
it becomes imperative to resort to surgical measures. These are 
fully outlined in the remarks upon the intranasal surgical treat- 
ment of chronic empyema of the frontal sinus, in the following 
paragraphs : — 

Treatment of Chronic Empyema. — Two general methods are 
employed for the treatment of chronic empyema .of the frontal 
sinus: (For description of suction treatment see page 577.) 

(a) The intranasal treatment (local and surgical) ; 

(b) Treatment by external (radical) operation. 

The merits of both methods depend upon the duration and 
extent of the disease, the size of the sinus and the number of septa 
which it contains, and the presence or absence of similar involve- 
ment of the neighboring sinuses. 

A sinus of moderate size which is free from septa, and without 
extensive pathological changes in the lining mucosa or osseous 
walls, is usually amenable to treatment by the intranasal route. 
This especially is true in cases of empyema of the frontal sinus 
which are complicated by purulent ethmoiditis, wherein by a pre- 
liminarv excavation of the anterior ethmoidal cells the obstruction 
to the nasofrontaLduct is overcome and access to the frontal sinus 
through its ostium is provided. 

On the other hand, when deep-seated pathological changes have 
taken place in the lining mucosa or osseous walls of a sinus of large 
size and deep anteroposterior dimensions, and which contains one 
or more septa (Fig. 3S5) . the more radical external operative pro- 
cedures become necessary. 



THE FRONTAL SINUSES. 



597 



(a) The Intranasal Treatment. — The intranasal treatment of 
chronic empyema of the frontal sinus should be conducted about as 
follows : — 

1. Resort temporarily to the simple measures heretofore outlined 
for acute frontal sinusitis, hoping thereby to establish drainage and a 
final cure. 

2. When possible to insert a cannula (Fig. 381), irrigate the 
frontal sinus two or three times daily. 

3. Whenever the ethmoidal labyrinth is the seat of a complicating 
purulent inflammation, the middle turbinal should be removed (Fig. 
353) and the anterior ethmoidal cells excavated (see Chapter 
XXXIX), after which the daily irrigations of the frontal sinus are 
continued. 




us burrs and hani.lK 



4. If a polypus protrudes from the exit of the nasofrontal duct, 
it should be seized and withdrawn. 

5. it is feasible to curet (gently) the nasofrontal duct, providing 
it is easy of access, and even to enlarge it by curetting its anterior wall. 

6. Surgical enlargement of the nasofrontal duct by the removal 
of surrounding bone. 

Surgical enlargement of the nasofrontal duct throughout its entire 
course promotes drainage, permits a certain amount of curettage of the 
interior of the sinus, and renders it fairly accessible to lavage. Unfor- 
tunately, the procedure is attended by certain dangers, enumerated as 
follows : — 

(a) The sinus may lie absent, in which event (be drill or trephine 
might penetrate the meninges. 

(b) By wounding the olfactory fissure, which lies toward the 
median line, a pathway would lie opened for infection to invade the 
meninges 



598 



NOSE AXD NASAL ACCESSORY SINUSES. 



(c) Injury to the inner plate of the frontal bone. 

Halle employs a series of burrs and drills (big. 391) and by 
cutting forward removes a portion of the floor of the sinus. The 
posterior wall of the nasofrontal duct and the inner table of the frontal 
bone are guarded by a grooved protector which is previously intro- 
duced. The mucous membrane of the sinus is thus, to a considerable 
extent, exposed to view and may be subjected to further surgical 
treatment. 

An ingenious method for enlarging the nasofrontal duct has been 
devised by lngals,- by which a pilot probe is first passed through the 
duct into the sinus and left in situ, after which a hollow burr attached 
to a flexible sheath (Fig. 392) is slipped over i.t up to the nasal open- 
ing. The handle is then attached to the chuck of a dental engine or 
motor, by which means the burr is gradually forced along the retain- 
ing probe until it burrows its way into the sinus. The entire 
instrument is then withdrawn, and by means of a packer absorbent 
gauze medicated with 95 per cent, carbolic acid is introduced 




Fig. 392.— Ingals's pilot burr. A, pilot; B, burr; C, shield. 



through the enlarged canal and drawn backward, cauterizing its 
entire length. A permanent gold irrigating tube, the sinus end of 
which has received several longitudinal slits, producing a flare 
which is temporarily maintained at the size of the tube by means 
of a gelatin capsule (Fig. 3^3), is then introduced into the sinus. 
The gelatin soon dissolves and the free ends of the cannula spread 
and thus hold it in place. This method obviates some of the dangers 
and in favorable cases may effect a cure, without external deformity. 

(b) Treatment by External (Radical) Operation. — Objects 
to be attained: Briefly stated the purpose of the external (radical) 
operation upon the frontal sinus is to eradicate the diseased mucosa 
which lines its walls, to excavate all necrosis of its bony walls and 
surrounding structures, to remove such portions of the anterior and 
inferior walls as may be necessary to carry out the operative technique 
and to insure drainage, and finally to obliterate the entire cavity, 
including its infundibulum. in the hope that by so doing the rami- 
fications of the disease will be terminated once and for all. 

Various methods of external operation have been devised. Owing 
to the marked variations and abnormalities in the frontal sinuses, both 



-Transactions of the American Laryngological, Rhinological and Oto- 
logical Society, 1905, p. 183. 



THE FRONTAL SINUSES. 



599 



as to size, shape and the presence or absence of septa, and to the 
variable character and extent of the disease, it is obvious that any- 
external operative procedure must be the subject of accurate selec- 
tion, based upon wise judgment and careful orientation regarding 
the anatomical relations in each individual case. 

Indications. — External operative interference is indicated in acute 
purulent frontal sinusitis whenever the usual intranasal methods have 




Fig. 393. — Ingals's frontal sinus drainage tube. Actual size. At the 
top is shown the tube open; at the extreme left, part of a capsule which 
is to cover it for introduction; between this and the tube the actual size 
of the tube, and at the right, the size and shape of the lower end of the 
tube. Below, the tube is shown with the capsule applied ready for intro- 
duction. 

failed to check the pus formation, or the inflammatory conditions, 
luch conditions are evidenced by continued pain, failure to establish 
free drainage through the nasofrontal duct, external swelling, menin- 
geal irritation, diplopia, or severe vertigo, and in chronic cases whenever 
curettage of accompanying diseased ethmoid cells, removal of polypi 
and irrigation have failed. 




Fig. 394. — Killian's packing forceps. 



In detail the indications for the external (radical) operation upon 
the frontal sinus are : — 

(a) When associated with chronic purulent inflammation of the 
anterior ethmoidal- cells, or of the entire group of accessory sinuses 
(pansinusitis), in which degenerative changes in the lining mucosa 
have taken place. 

(b) When permanent remission of symptoms does not follow the 
intranasal procedures enumerated in the preceding paragraphs, espe- 
cially the removal of the anterior end of the middle turbinal and 
irrigation of the sinus. 

(c) When the skiagraph reveals no1 only empyema, but sinuses 
of large dimensions with multiple septa. 



600 



NOSE AND XASAL ACCESSORY SINUSES. 



(d) When necrosis of the walls of the sinus and fistula are 
manifest. 

{e) When the conformity of the nose renders intranasal treat- 
ment difficult or impossible, or when anomalies of drainage are sus- 
pected, e.g., drainage of the frontal sinus into the maxillary antrum. 

Until about twelve years ago the radical operative treatment of 
purulent frontal sinusitis was resorted to only in the presence of 
dangerous complications or fistula. The operative era was inaugurated 
in 1893 by Luc, Kuhnt, Jansen, Killian, and others. 




Fig. 395.— Killian's operation. First step, showing line of initial in- 
cision with slight transverse cutaneous cuts. The initial incision is made 
through the soft structure to the periosteum. {Harmon Smith, with per- 
mission.) 



The Luc Operation (the Ogston-Luc procedure). — In this opera- 
tion the primary incision extends along the supraorbital ridge, 
over its inner one-third, comencing about 1 centimeter from the median 
line. After retracting the periosteum the anterior wall of the sinus 
is partially resected. Through this opening the cavity of the sinus is 
scraped and free communication established into the nasal cavity, 
through the nasofrontal duct. The entire external wound is then 
closed by sutures. 

The Kuhnt Operation. — In Kuhnt's operation the anterior wall 
of the sinus is entirely removed, a vertical incision being carried upward 
from the mesial end of the primary incision along the eyebrow. The 
entire membranous lining and all bony septa are then removed from the 



THE FRONTAL SINUSES. 



601 



sinus. The anterior ethmoidal cells also are removed when diseased. 
Kuhnt personally advised that the external wound should not be closed, 
and that a wide communication with the nasal cavity as a septic 
centre should be avoided, providing the ethmoidal labyrinth is 
healthy. Luc and Hajek modified the operation by introducing a 
drainage tube from the sinus cavity into the nose and closing the 
external wound, thus securing far better cosmetic results. Ler- 
moyez and Tilley follow practically the same procedure. 

The Killian Operation. — The Killian operation is favored by a 




Fig. 396.— Killi 

retracted, and lim 
permission.) 



; operation. Sscond step showing soft tissues 
)f periosteal incisions. {Harmon Smith, with 



majority of rhinologists. It is somewhat complicated in technique, but 
the excellent cosmetic results attained, the wide-open drainage into 
the nasal cavity and the admirable opportunity which thereby is 
afforded to excavate the ethmoidal labyrinth and the sphenoidal 
sinus are strong arguments in its favor. 

Technique. — The steps of the operation arc as follows ( Harmon 
Smith's description of the technique is herein adopted in part)! — 

The patient is prepared in accordance with approved surgical 
requirements. The operation is performed under general anesthesia. 
At the time of operation, as soon as the anesthetic has been admin- 
istered, the operative field should again be carefully scrubbed with 
ether solution, the eyelids covered with pledgets of sterile gauze, a 



602 ' NOSE AND NASAL ACCESSORY SINUSES. 

rubber cap so placed upon the head as to include all the hair, and 
this in turn covered by a moist bichlorid towel.. If possible there 
should be two assistants besides the anesthetizer and nurses. 

The eyebrow is not shaved, but, if the brow is "heavy" and the 
hairs long, they may be clipped. Three or four long tampons of 
absorbent cotton are then introduced deeply into the nasal cavity of the 
side to be operated upon, by means of the Killian forceps (Fig. 394). 

The incision which divides the skin, subcutaneous and muscular 
tissues, but not the periosteum, is then extended from the outer third 
of the orbit, through the centre of the hair line to the root of the 




Fig. 397.— The Killian protector. 



nose and thence curved sharply downward and slightly outward to 
a point slightly below the inferior margin of the nasal bone (Fig. 
395). 

The line of incision is marked by several slight crosscuts for the 
purpose of perfect coaptation of the wound margins upon the com- 
pletion of the operation. The soft tissues are then retracted from the 
periosteum to prepare the way for the periosteal incisions. 

The Periosteal Incisions. — 1. The periosteum is divided trans- 
versely, from the median line of the forehead to the outer extremity of 
the wound, parallel to but in a plane about 6 millimeters above the 
supraorbital ridge. 

2. A second periosteal incision is commenced at a point underneath 
the supraorbital ridge and just internal to the attachment of the pulley 



-Killian's V-shaped chisel. 

of the superior oblique muscle, and is extended downward along the 
line of the primary incision (Fig. 396). The periosteum is elevated 
upward from the transverse incision until the anterior wall of the' sinus 
is fully exposed, and downward from the lower incision until the inner 
third of the supraorbital wall (floor of the sinus) is denuded. Mean- 
time the eye should be protected by means of the Killian protector 
(Fig. 397). 

This leaves a strip of periosteum undetached from the bridge cf 
bone which is to serve the purpose of maintaining the contour of the 
parts. • 

3. The retraction of the periosteum from the supraorbital region 
gives rise to severe hemorrhage, and this space should be packed with 
gauze which has been saturated with adrenalin solution 1 : 5000, pending 
the removal of the anterior wall of the sinus. 

4. Enter the anterior wall of the sinus by means of gouge and 




Fig. 399. — Killian's operation, third step. 1. The bridge of bone with 
its periosteal covering If ft in place fur upholding the soft tissues upon 
closure of the wound. 2, The entrance through the os planum into the 
ethmoidal tract extending back into the sphenoid. 3. The size of the sinus 
in this ease with its irregular outlines and deep sulci 4. The little nicks in 
the initial incision which must he approximated in closing the wounds to 
preserve the integrity of the parts. (Harmon Smith, with permission.) 



THE FRONTAL SINUSES. 



603 



mallet, just above the bridge of bone lying between the periosteal 
incisions. 

5. From this point, using the Killian V-shaped chisel (Fig. 398), 
excavate a groove of bone, following transversely from the primary 
opening along the line of the first periosteal incision to the outer angle 
of the wound. Remove a large section of the anterior wall of the sinus 
with rongeur forceps. 

During the removal of the bone of the outer (anterior) wall it is 
unnecessary to break through the underlying mucosa. After sufficient 
bone has been removed, an incision should be made through the mucous 




Fig. 400. — Killian's operation. Lateral appearance after dividing the 
head, a, Entrance through os planum and orbit into the ethmoidal tract. 
b, The ethmoidal tract, c, Sphenoidal sinus, d, Line of attachment of 
middle turbinate, e, Inferior turbinate. (Harmon Smith, with permis- 
sion.) 



membrane, and its thickness and general condition noted. It is not 
unusual to find diseased, edematous mucous membrane of a thickness of 
1 centimeter. Pus in large quantities is not always present, but the 
space may be partially or wholly occupied by thickened membrane and 
edematous polypi. 

6. Having probed the sinus to verify the skiagraphic estimate of 
its extent, the remaining portion of the cuter wall should be removed 
with rongeur forceps and chisel. 

7. Remove the entire contents of the sinus, including the lining 
mucosa, with a sharp enret, and break down all septa and smooth off 
all rough edges of bone ( hig. 399). 



604 



NOSE AND NASAL ACCESSORY SINUSES. 



8. Return to the lower portion of the wound, withdraw the 
gauze packing, and then remove the inferior (supraorbital) wall of 
the sinus, meanwhile guarding the bridge of bone which is to be 
left in situ. r l nis opening should be extended toward the nasal 
bridge and downward a considerable distance to facilitate further 
operative procedures. The latter requires the removal of the frontal 
process of the superior maxillary and the entire sinus floor 
(Fig. 399). 




Fig. 401. — Briining's forceps. 



9. When the ethmoidal labyrinth is diseased the entire system of 
cells should be removed, one after another, including the middle 
turbinal (Fig. 400). In this procedure all careless manipulation of 
instruments should be avoided, especially when excavating in the region 
of the cribriform plate. The evulsion forceps (Fig. 401 ) is a remark- 
ably effective instrument for removing the diseased ethmoidal cells and 
their retained polypi, and it is proportionately a safe instrument. 




Griinwald's sphern lidal 

forceps. 



Likewise remove the anterior wall of the sphenoidal sinus and 
curet its cavity (Fig. 400). The Grunwald bone forceps (Fig. 402) 
are most serviceable and effective for biting away the bony anterior 
wall. Complete the operation by carefully removing any remaining 
membranous lining of the nasofrontal duct. In case the inner (vis- 
ceral) cranial table is eroded at any point, remove the necrosed bone 
and expose a considerable area of dura. 

10. Irrigate the wound with a warm physiological salt solution, 
wipe the surfaces dry, and pack the wound lightly from the outer angle 
forward, with one strip of gauze, and push its remaining end 
downward through the frontonasal opening into the vestibule of the 
nose. Likewise pack the ethmoidal and sphenoidal regions. Close 
the external wound with sutures, which should include the perios- 



THE FRONTAL SINUSES. 



605 



teum, particularly about the inner angle of the eye. In closing the 
wound, advantage should be taken of the small cross incisions 
(Fig. 395) to insure perfect coaptation of the soft tissues. 

Killian employs fine-wire sutures with excellent results. They 
•are objectionable on account of the severe pain which is induced by 
their removal. The author commends silkworm gut for closing the 
external wound. 

Before applying the external dressings the fatty tissues of the orbit 
should be carefully pressed upward into the sinus cavity. Pads of 
gauze are then placed over the closed eye, and loose gauze over the 




entire operative field, and a firm bandage applied.' A complete set, 
of instruments for performing the operation upon the nasal acces- 
sory sinuses is shown in Fig. -103. 

' After-treatment. — The patient should lie on the healthy side 
for (he most part, and blowing of the nose should he forbidden, lie 
must aspirate the secretions backward into the pharynx, and thus avoid 
inflation of the frontal sinus. Change the outer dressings daily and 
the inner gauze packing on the second or third day. and daily there- 
after. Remove the sutures in from the Fourth to the seventh daw 

As a rule, irrigation should be dispensed with. The care of the 
internal wound may extend over a period of from one to three months. 
Exuberanl granulations musl lie reduced by applications of nitrate of 
silver or fused chromic acid. The deformity gradually becomes less 



606 NOSE AND NASAL ACCESSORY SINUSES. 

noticeable as the sinus cavity becomes filled in with granulations and 
the orbital fat. 

Finally, if a disfiguring depression results, it may be filled in by 
subcutaneous injections of paraffin. 

Killian claims that this operation, when skillfully performed, 
results in but little external deformity, requires but a short sojourn 
in the hospital, and is adaptable to the majority of cases. In actual 
practice this claim is well founded. 

Furthermore, the Killian operation is particularly applicable in 
cases which are complicated by ethmoidal and sphenoidal disease (Fig. 




Fig. 404. — Photograph showing cosmetic results of a Killian frontal 
sinus and antrum operation upon the left side. (Author's case.) 

400). Figures 404 and 405 are photographs of two cases of unilat- 
eral pansinusitis, where the author employed the Killian operation 
with but slight external deformity. 

The External (Radical) Operation by the Open Method. — 
The radical operation by the open method is advocated by many 
American rhinologists. In this operation the entire anterior wall of 
the frontal sinus is removed precisely as in the Kuhnt procedure. The 
mucous membrane lining the cavity of the sinus and all septa are 
entirely removed. A strip of gauze is drawn downward through the 
infuhdibulum into the nose and "seesawed" back and forth until the 
mucous membrane of the frontonasal duct is denuded; when the 
neighboring ethmoidal cells are diseased they are broken down and 
removed. 



THE FRONTAL SINUSES. 



607 



The entire denuded cavity is then packed with gauze. Drainage 
into the nasal cavity is avoided by packing the wound externally from 
below upward, thus leaving the lower portion to granulate and close off. 
The first packing should both fill the wound in the bone and widely 
separate the skin wound. The -wound cavity is thus allowed to granu- 
late and heal from the bottom in the manner usually adopted in bone 
operations elsewhere, notably those upon the mastoid process. The 
entire wound and the surrounding area are covered with sterile dress- 
ings and a bandage is applied. Thereafter the wound is dressed as an 
open wound. The deep dressings are changed on the sixth day, pro- 
viding no untoward symptoms arise. The outer dressings should be 
changed daily. 

The granulations finally fill the wound cavity in about five or six 
weeks. In the meantime its communication with the nose will have 
terminated by the growth of granulations 
from below. On account of the scar, which 
is as a rule adherent, the deformity following 
this operation is more conspicuous than in 
that from the Killian operation. The de- 
formity may be partially overcome by resect- 
ing the scar at a subsequent operation, or by 
a subcutaneous injection of paraffin. 

Difficulties and Dangers Associated 
with the External (Radical) Operation 
upon the Frontal Sinus — 1. It is difficult 
to obtain the patient's consent to so formid- 
able a procedure, which may possibly disfigure 
the face. In the author's case hereinafter 
reported it was only after repeated warnings, 
covering a period of several months, that 
the patient finally submitted to operation. 

2. It cannot truthfully be affirmed that 
the operation invariably is without danger, 
inasmuch as fatalities occur which are in no 

wise due to faulty technique. Tilly, St. Clair Thomson, Milligan, Lack, 
Turner and others of like skill and experience have reported fatal cases. 
It is to be regretted that so few operators publish the reports of their 
fatalities, five of which were reported by Luc out of his first thirty 
operations. The majority of fatal cases are those wherein the infection 
already has invaded the meninges, with resultant local or general 
meningeal inflammation, or brain abscess. One fatal case in the 
author's practice resulted from a sudden extension of a brain abscess 
which undoubtedly had existed, unaccompanied by serious symptoms, 
for some months. 

For five months this patient repeatedly had been urged to submit 
to an external ( radical ) operation upon both frontal sinuses, on account 
of the apparent extensive changes which had taken place in the lining 
mucosa of these cavities. At times he had suffered from frontal head- 
ache, which was attributed to the pressure of the masses of polypi in 
his sinuses, and to exacerbations of the inflammation. During this 




Fig. 405. — Cosmetic 
results of a Killian 
frontal sinus operation 
upon the left side. (Au- 
thor's case.) 



608 NOSE AND XASAL ACCESSORY SINUSES. 

period his anterior ethmoidal cells had been excavated through 
the nares. The diagnosis was verified by a skiagraph. lie finally 
gave his consent and the external operation was performed upon 
both sinuses. They were extensively diseased. The after-treatment 
was by the open method. 

Several days after the operation the patient began to complain of 
headache, which was greatest in the frontal and occipital regions, 
lie had one slight chill but no acceleration of temperature, and no 
choked disk or other ocular symptoms. His attending physician 
reported that a large amount of pus was flowing from his nose and 
considerable into his sinus wound. 1 1 is weakness continued, the 
pain increased, and finally a swelling appeared over the right frontal 
region, extending 2 x / 2 inches above the eyebrow. Three days later 
he had become partially unconscious, his temperature was 101-j4°, 
the pulse 106 and the respiration 2&. At this time it was impossible 
to make a satisfactory examination of the fundi. There was slight 
muscular twitching and some rigidity of the neck. There was an 
enormous swelling over the frontal bone, toward the right side. 

Second Operation. — The old scars were reopened and the scalp 
thrown upward, uncovering the entire lower portion of the frontal bone, 
the outer table of which was necrotic. At a point about one inch 
above the upper border of the frontal sinus there were two small 
fistulous openings communicating with the cranial cavity, from 
which there was a flow of pus apparently under pressure. The sur- 
rounding necrosed bone was quickly curetted and the exposed dura 
was covered with granulations, except at the point from which the 
pus made its exit. Upon enlarging the opening in the dura a large 
abscess was found in the frontal lobe. The abscess was treated in 
the usual manner, but the patient never regained consciousness and 
died two days later. The temperature following operation ranged 
between 104° and 106°. Had this patient consented to the opera- 
tion four months earlier his life might have been saved. 

3. Meningitis may be present either as a recognized state or in 
its incipient stage, even at the time of the operation, in which event 
the patient's life is jeopardized not by the operation, but by the 
accompanying meningeal involvement. 

4. If, during the operation, the dura is exposed, either accidentally 
or by intent for the purpose of removing necrosed bone, the 
exposure should be enlarged sufficiently to permit free drainage from 
its surface. Otherwise there is clanger from infection. 

5. Finally, the lowered vitality and lack of resistance which result 
from the long-continued suppuration from the nasal accessory 
sinuses predispose to renewed infection. 



CHAPTER XXXIX. 

DISEASES OF THE NASAL ACCESSORY SINUSES, 
{Continued.) 



I. THE ETHMOIDAL SINUSES (ANTERIOR AND 
POSTERIOR ETHMOIDAL CELLS). 

Anatomy. — The ethmoidal sinuses, usually described as eth- 
moidal cells, are practically absent at birth. They develop gradually 
during- infancy and childhood, by a process of protrusion into the 
cartilaginous ethmoid (Lack). They lie within the two sides of the 
ethmoid bone, each set of cells having at least two subdivisions, 
which are termed the anterior and the posterior ethmoid cells (Figs. 
363, 378 and 400). This classification is based upon their location 
in the ethmoid bone and upon the meatus into which they drain. 
The anterior ethmoidal cells, numbering from two to eight, are 
generally smaller than the posterior and they open into the middle 
meatus. The posterior ethmoidal cells, fewer in number and larger 
in size, are usually situated upon a plane slightly lower than the 
anterior, and open into the superior meatus. Jn general they occupy 
the region above and external to the middle turbinal. The orbital 
plate constitutes the outer boundary, and the cribriform plate the 
superior boundary of these cells, which rarely extend beyond the 
confines of the ethmoid bone. Sometimes an ethmoidal cell 
encroaches on the frontal sinus, when it is known as a fronto- 
ethmoidal cell. The cavities are asymmetrical and of irregular size 
and number, and together these are often spoken of as the ethmoidal 
labyrinths. 

The separation of the ethmoidal cells from the brain is by 
means of thin, but rather dense bony walls, and a portion of the 
orbital plate is sometimes substituted by membrane. The optic 
nerve commonly lies in direct relation to the posterior group of 
ethmoidal cells (Fig. 406). A similar relationship exists between 
the ethmoidal cells and the remaining accessory sinuses (sphe- 
noidal, frontal and maxillary), from which normally they are walled 
off by thin, bony septa. The latter readily become broken down as 
a result of prolonged purulent processes, and thus open up a direct 
pathway of infection to the neighboring sinuses. Each ethmoidal 
sinus as a whole varies from 2Yi to 3 cm. in length and from 1 to 
V/ 2 cm. both in height and width. A\ Ten healthy and but few in 
number each cell lias a direct opening into the nasal cavity, but 
when diseased their septa are prone to break down, and as a result 
they open freely into each other. 

The ethmoidal cells are lined by a mucous membrane which is 
much thinner and less dense in construction than that of the frontal 
and maxillary sinuses. 

3» (609) 



610 



NOSE AND NASAL ACCESSORY SINUSES. 



DISEASES OF THE ETHMOIDAL CELLS. 

The affections of the ethmoidal cells herein described are : — 

1. Acute inflammation. 

2. Chronic purulent ethmoiditis. 

Other lesions, particularly the neoplasms, are considered in 
the general chapter on Neoplasms of the Nose. 

1. Acute Inflammation of the Ethmoidal Cells. 

Definition. — An acute inflammatory invasion of the lining 
membrane of the ethmoidal cells, usually occurring as an extension 




Fig. 406. — Left sphenoid (sss) small, not in relation with chiasm; right 
sphenoid (ssd) apparently double, on account of a ridge in relation with 
chiasm posteriorly; relation of posterior ethmoid cells (ccps, cepd) well 
shown at posteroexternal angle; sfs, sfd, frontal sinuses; cis, cid, inter- 
nal carotid. (Loch, with permission.) 

from acute rhinitis, and accompanied by altered secretions, with or 
without retention. 

Etiology. — The most common cause of acute ethmoiditis is 
acute rhinitis. Invasion of the ethmoidal cells is more likely to 
occur in cases wherein the accompanying rhinitis is the result of 
definite infections like the grippe, the exanthemata, typhoid fever, 
sepsis from intranasal operations, and tertiary syphilis. Further- 
more, the ethmoidal involvement may occur by direct extension 
from that of a neighboring accessory sinus. 

Pathology. — The pathological changes are characterized by 
turgescence of the mucosal lining of the cells involved, and more 
or less swelling and redness of the mucosa of the middle turbinal, 



THE ETHMOIDAL SINUSES. 611 

and a profuse outpouring- of mucus, mucopurulent or purulent 
secretion. When retention of secretions occurs, the mucosa both 
within and surrounding the cells involved becomes edematous ; mean- 
while bulging of the cell walls and external swelling may ensue. 

Symptoms. — The symptoms vary in accordance with the group 
of cells which are involved, the severity of the process and the 
degree of retention of the secretions. In its simplest form and 
when due to simple acute rhinitis there is a sensation of fullness 
between the eyes, and occasionally moderate pain in the ethmoidal 
region and about the nasal bones. Unless retention occurs the 
attack subsides with the cessation of the acute rhinitis. In cases 
wherein the sinus openings (ostei) become occluded as a result of 
inflammatory thickening, from polypi or other tumors, or as a 
result of intranasal obstruction (septal deflections, enlarged or 
deformed turbinals, etc.), the symptoms are proportionately more 
severe and prolonged. 

The pressure of the retained secretions induces pain between 
the eyes, which may radiate to the orbital and frontal regions, and 
tenderness on pressure over the ethmoidal region. Nasal respira- 
tion becomes impeded and external swelling may ensue. During 
the early stages the secretion is mucoid or mucopurulent, but in 
severe types, especially when retention of the secretions is pro- 
longed, it becomes purulent. In the majority of cases the pent-up 
secretions finally force an outlet through the normal openings of 
the cells, and relief immediately ensues. In others relief is obtained 
by appropriate treatment. But, if the disease is permitted to 
progress without either spontaneous recovery or relief by treat- 
ment, it may eventuate in chronic ethmoiditis. 

Diagnosis. — The diagnosis of acute ethmoiditis when the dis- 
ease is confined to the anterior group of cells is comparatively 
simple. The history, the symptoms, the swollen and inflamed 
appearance of the middle turbinal tissues, and the flow of secretions 
from the middle meatus, in the absence of positive signs of frontal 
sinusitis and maxillary sinusitis, is usually sufficient to establish a 
diagnosis. 

Treatment. — Primarily the underlying acute rhinitis should 
receive prompt and vigorous treatment (see Chapter XXXIII), 
and measures should be adopted that will favor the customary 
free drainage of the ethmoidal cells. In case of retention of the 
secretions within the ethmoidal cells efforts should be made to 
establish drainage, and the following procedures are advised: — 

After spraying the nostril with warm alkaline solution, a small 
amount of a solution of cocaine 4 per cent, in adrenalin 1:5000 
should be sprayed directly upon the tissues of the middle turbinal 
and the lateral nasal wall of the middle meatus. After a few 
minutes small flattened-oul tampons of absorbenl cotton soaked 
with the same solution ( Fig. 347) are gently crowded into the chink 
between the middle turbinal and the lateral nasal wall and allowed 
to remain For twenty minutes. The contraction of the swollen 
tissues Following tin's procedure serves to open the ostei of the cells 



612 NOSE AXD XASAL ACCESSORY SINUSES. 

and release the pent-up secretions. Several repetitions of this pro- 
cedure covering- varying periods, particularly in severe cases, are 
often necessary, both for the relief of symptoms and to establish an 
open drainage of the cells. 

In case of obstruction of drainage resulting from polypi, 
enlarged middle turbinate, or deflections of the septum, it sometimes 
becomes necessary to resort to appropriate operative procedures in 
order to obtain relief. As the acute rhinitis and ethmoiditis sub- 
side, mild astringents may be applied to the mucosa of the ethmoi- 
dal regions. For this purpose an application of a 25 per cent. 
solution of argyrol is effective. The Douglas formula of benzoinol 
(see page 496) lias a slightly astringent and at he same time a most 
soothing effect, and may be freely employed as a spray. 

Local bloodletting, through a series of incisions into the mucous 
membrane, along the anterior and inferior surfaces of the middle 
turbinal and along the lateral nasal wall in the vicinity of the hiatus 
semilunaris, is recommended by Lake. 

2. Chronic Purulent Ethmoiditis. 

Definition. — This affection is characterized by a chronic inflam- 
matory process which involves the mucosa of the ethmoidal cells, 
attended by a purulent discharge. When drainage is free and 
unimpeded the empyema is termed "open." Prolonged retention 
of secretion from closure of the openings of the cells is defined as 
"closed empyema." 

Etiology. — Repeated attacks of acute ethmoiditis, superinduced 
both by acute and chronic rhinitis, account for a large proportion 
of all cases of the chronic form of the disease. 

The contributing and often determining causes are : — 

(a) Specific infections, such as influenza, measles, scarlet fever, 
diphtheria, and typhoid fever. 

(b) The ravages of intranasal tertiary syphilis, and neoplasms. 

(c) Exhaustion from disease, constitutional taint, perverted 
habits, bad hygienic surroundings, or overindulgence in tobacco and 
alcohol. 

(d) Obstruction of the openings (ostei) of the cells from 
hyperplasia, edematous polypi, enlarged or cystic turbinate, or 
septal deflections. 

(<?) Concurrent empyema of the neighboring sinuses. 

(/) Pathological changes in the structure of the mucosa of the 
cells and in their bony walls, which have resulted directly from 
acute attacks of purulent ethmoiditis. 

Pathology. — Pathological changes in the mucoperiosteal lining 
of the cells, in the order of occurrence, comprise: 1, inflammatory 
thickening, edema and destruction of the ciliated epithelium ; 2, 
as the hyperplasia extends to the submucosa and periosteum, 
edematous tumors (polypi) are prone to develop, and may protrude 
through the ostei of the cells; 3, in cases of closed empyema, pres- 
sure of the retained secretions may eventuate in destruction of the 
cell walls, and escape of purulent secretion, either into the orbit, the 



THE ETHMOIDAL SINUSES. 613 

nose, or the cranial cavity. It is quite common for the dividing 
walls between one or more cells thus to break down and form one 
large cell, which may become the seat of latent empyema or contain 
a mucocele. According to Hajek, the polypi, both within the cells 
and surrounding the middle turbinal, are the product of a chronic 
hyperplastic inflammation of the membranous covering of the 
ethmoid, the anatomical topography of the ethmoid bone being 
conducive to this edematous mucous-membrane degeneration. 

The pathological changes may involve one or more cells of the 
anterior or the posterior group, on one or both sides of the nose. 

Symptoms and Course. — Pain is not a constant symptom of 
chronic purulent ethmoiditis except during exacerbations. The 
pain is usually described as a dull, heavy sensation of pressure 
between the eyes, which often radiates into the frontal region. It is 
also experienced at the base of the skull when the posterior eth- 
moidal cells are involved. Tenderness on pressure is rare except 
during exacerbations, when it may be elicited by pressure inward 
and backward, at a point between the inner canthus of the eye and 
the nasofrontal and nasomaxillary articulations. 

Pus discharge from the ethmoidal cells is the most prominent 
and constant symptom of this disease. Unlike the maxillary 
antrum, the discharge from the ethmoidal cells is more likely to 
be constant, and it is more profuse when the patient is in an upright 
position. Furthermore, there is a quick return of pus after wiping 
out the middle meatus. A single polypus may project from the 
ostium of the maxillary or the frontal sinus; but a pus discharge 
flowing over the surfaces of several small polypi, situated about the 
under surface of the middle turbinal, and the space between that 
body and the lateral nasal wall, is presumptive evidence of purulent 
involvement of one or more cells of the anterior group, which 
may or may not be independent of concurrent empyema of the 
frontal and maxillary sinuses. 

The intimate relation of the outlets of the frontal and max- 
illary sinuses with those of the anterior ethmoidal cells renders it 
extremely difficult to determine the source of pus which accumu- 
lates or Hows from the middle meatus external to the middle 
turbinal. By carefully plugging that part of the middle meatus 
lying above the ostium maxillare, it is sometimes possible to shut 
off the flow from the nasofrontal duct and the anterior ethmoidal 
cells, in which event, if the flow continues, it probably comes from 
the maxillary antrum. 

It is more difficult, and often impossible, to differentiate 
between the flow from the nasofrontal duct and the anterior eth- 
moidal cells. In the former the pus usually is located high up and 
well forward in the hiatus semilunaris. Attempts have been made 
— and sometimes successfully — to shnt off the opening of the hiatus 
semilunaris by inserting small plugs high up. A cessation of dis- 
charge following this procedure is evidence of frontal sinus 
empyema, and, per contra, a continuation of 1 1 1 * - flow would indicate 
empyema of the anterior ethmoidal cells or maxillary antrum. 



614 NOSE AND NASAL ACCESSORY SINUSES. 

The discharge from the posterior group of ethmoidal cells 
flows into the superior meatus, and may he seen in the olfactory 
fissure between the septum and the middle turbinal ; but in the 
main it flows backward and downward into the postnasal space. 

Open empyema of the ethmoidal cells, even when chronic, may 
pass through latent periods, the latent periods being characterized 
by a partial or complete cessation of pus flow and of the general 
symptoms of the disease, and also by the absence of visible and 
palpable indications of disease of the parts. This latent condition 
is possible only in cases where no deep-seated structural changes 
have taken place as a result of the prolonged infection. Necrosis of 
the middle turbinal and ethmoidal cells is rare. When present it 
may be determined by means of the examining probe. Further 
evidence of ethmoidal empyema is found in the structural changes 
in the middle turbinal, whereby its anterior and inferior portions 
become cystic. External swelling and protrusion of the inner wall 
of the orbit, pus sinuses in the region of the inner canthus, or flat- 
tening or enlargement of the side of the nose are the chief external 
evidences of extensive distention of the ethmoidal cells. 

In chronic purulent ethmoiditis the discharge is commonly 
profuse, and during the night considerable collections both of fluid 
and inspissated pus accumulate in the postnasal space. Crust 
accumulations in the middle nasal meatus are common and may 
simulate ozena. Polypi, usually multiple, are a common complica- 
tion, and they may occupy the cavities of the cells, protrude from 
their openings, or spring from the-free surface of the middle turbinal. 
When polypi spring from the posterior third of the middle turbinal, 
strong presumptive evidence of empyema of the posterior group of 
ethmoidal cells is thereby furnished. 

It is often difficult to differentiate empyema of the posterior 
ethmoidal cells from empyema of the sphenoidal sinus. More 
recent researches have shown that changes in the ethmoid bone 
(caries) are by no means rare in prolonged empyema of the eth- 
moidal cells. Griinwald demonstrated this condition in 31 out of 
55 cases of ethmoidal suppuration. 

As a result of prolonged pressure of the retained secretions, in 
retention cases, the cavities of the ethmoidal cells are liable 
to become distended, giving rise to the formation of mucocele. 
The most susceptible cell to mucocele development is the one 
situated at the anterior end of the ethmoidal labyrinth, but other 
ethmoidal cells are by no means exempt. These cysts may 
protrude either into the nose or into the orbit. They are differen- 
tiated from exostoses, which develop gradually and painlessly, 
while the former show a fluctuating contrast unless the abscess 
walls are intact. 

Prolonged purulent ethmoiditis may finally lessen or pervert the 
sense of smell. The author has had a series of cases of chronic 
ethmoiditis of grippe origin which resulted in permanent anosmia. 
Chronic purulent ethmoiditis is a constant menace to the ears on 
account of the danger of middle-ear infection. Furthermore, the 



THE ETHMOIDAL SINUSES. 615 

obstructive character of the ethmoidal lesion tends to impede the 
normal aeration of the Eustachian tube. In the more severe cases, 
wherein the pus retention produces great pressure, the orbital plate 
of the ethmoidal bone breaks down and permits the escape of pus 
into the orbit, where it causes exophthalmos. General impairment 
of the health is not usually marked, although it may be present. 
Insomnia, aprosexia, mental depression and neurasthenic phenomena 
at times accompany ethmoidal sinusitis. 

Diagnosis. — Method of examination : A complete history having 
been obtained, a painstaking rhinoscopic examination, under bright 
illumination, should be made as follows: 1. Caution the patient 
not to blow out the secretions until the first inspection is com- 
plete (it is natural for patients to blow the nose just before entering 
the rhinologist's office). 2. Note the amount, quality and location 
of the secretion, and the condition of the middle turbinal and its 
surrounding mucosa. 3. After spraying away all secretions, employ 
cocaine and adrenalin solutions for the purpose of local anesthesia 
and shrinkage of soft tissues. If pus is observed in the middle 
meatus external to the middle turbinal, it must come from one of 
three sources, viz., the maxillary antrum, the frontal sinus, or the 
anterior ethmoidal cells. Often two or all of these sinuses are 
involved. By washing out the maxillary sinus, preferably through 
an opening underneath the inferior turbinal (Chapter XXXVII), 
empyema of this cavity is determined, and transillumination (Fig. 
367} is a valuable differential aid. Likewise, douching the frontal 
sinus whenever possible to do so aids materially in demonstrating 
whether or not this cavity is involved. Simultaneous flushing of 
the frontal and maxillary sinuses, when immediately followed by 
pus flow into the middle meatus, indicates empyema of the anterior 
ethmoidal cells. In typical cases the pus emerges from the point of 
junction between the bulla ethmoidalis and the middle turbinal. 
4. It is often necessary to freely expose this point by resecting the 
anterior third of the middle turbinal (Fig. 353), and the removal of 
all polypi or other obstructing hypertrophies. 5. A cystic or other- 
wise enlarged middle turbinal (Fig. 346), particularly if accom- 
panied by a pus discharge, or polypoid degeneration, is strong 
presumptive evidence of purulent ethmoiditis. 6. Transillumination 
possesses no value in the diagnosis of empyema. of the ethmoidal 
cells. 7. Skiagraphy is a valuable means of determining purulent 
ethmoiditis. As heretofore remarked (Chapter XXXVIII), skiag- 
raphy (if the nasal accessory sinuses is a most difficult procedure, 
and only the most skillful roentgenologists are capable of producing 
reliable results. In Fig. 384 the skiagraph shows disease of the 
ethmoidal sinuses. 8. Finally, it is sometimes necessary to explore 
the cells in order to determine the character and extent of the 
purulent invasion. 

Prognosis. — The prognosis in the more simple cases is favor- 
able, especially when subjected to proper treatment. Closed empyemas 
are prone to result in extensive polypoid degeneration and in varying 
degrees of necrosis of the ethmoid hone, unless subjected to surgical 



(,16 NOSE AND NASAL ACCESSORY SINUSES. 

treatment. The necrosed areas may involve the orbital plate of the 
ethmoid, the lachrymal bone, or even the meninges, with fatal results. 

Treatment. — The principles involved in the treatment of 
chronic purulent ethmoiditis are: 1, the removal of the diseased 
areas, and, 2, the establishment of ample drainage of the ethmoidal 
cells. (For description of suction treatment see page 577.) 

Purulent disease of the ethmoidal labyrinth, except when the 
necrotic process has extended into or beyond the surrounding walls of 
the ethmoid bone, is usually amenable to intranasal surgical treatment. 
The anterior cells are sometimes most difficult to reach, but. according 
to Hajek, they can always be excavated, providing the middle turbinal 
has been resected. The complete labyrinth is shown in one of the 
superb sections prepared by Loeb (Fig. 407). 

The various operative procedures are classified under three gen- 
eral headings : — 

1. Partial excavation of the ethmoidal labyrinth by the intranasal 
route. 

2. Complete removal of one or both groups by the intranasal route. 

3. Complete removal by external operation. 

1. Partial Excavation. — Partial removal of the ethmoidal cells 
is applicable to cases wherein the disease is more or less localized 
and confined to one or more of the larger anterior cells. All opera- 
tions upon the ethmoidal cells require a -more or less complete 
removal of the middle turbinal as a preliminary measure ; hence the 
anterior end (big- 353) of the middle turbinal must be resected 
before attempting the operation for partial excavation of the dis- 
eased cells and their contents. 

The preparations, both regarding local anesthesia and shrinkage of 
the tissues with adrenalin, should be carried out precisely as described 
for operations upon the middle turbinal (see Chapter XXXVI). By 
following the course of the pus flow or tracing the site of attach- 
ment of any polypi, the affected cells are discovered and entered one 
after the other, by means of a small, sharp, slightlv curved curet 
(Fig. 403), or suitable punch forceps. The Briinings forceps (Fig. 
401) are most adaptable and safe for the purpose of extracting granu- 
lation polypoid masses, and for detaching and removing the thin 
lamina? of bone. In other words, the operation consists in removing 
the obstructing lesion, and the establishment of free drainage, mean- 
while depending upon intranasal washing or spraying to maintain 
cleanliness during the healing process. The galvanocautery is men- 
tioned merely to be condemned as a measure for reducing the middle 
turbinal, since it may cause dangerous inflammatory reaction. 

Hemorrhage during the operation is rarely troublesome, and is 
controllable by repeated applications of suprarenal solution or tempo- 
rary packing with gauze. 

2. Complete Removal of the Ethmoidal Cells by the Intra- 
nasal Route. — The indications for the intranasal method, according to 
Hajek, are: 1, in all cases of chronic latent empyema of the 
ethmoidal labyrinth, with or without extension toward the nasal 
cavity; 2, in acute empyema of the labyrinth, in the presence of 



THE ETHMOIDAL SINUSES. 



617 



symptoms of imminent rupture toward the orbit. The steps are as 
follows : — 

(a) Local anesthesia and adrenalin contraction of the soft 
tissues is preferable to general anesthesia, but the latter is some- 
times necessary when operating upon neurotic individuals. 

(b) Remove the middle turbinal en masse. (See Chapter 
XXXVI.) 




^snomd 



airy 

Fig. 4(17. — Whole left labyrinth exposed (ccps, ceas) ; each sphenoid 
(sss, ssd) in relation with corresponding optic nerve and chiasm; last 
posterior ethmoid cells (ccps, cepd) show usual relation with optic nerve 
at posteroexternal angle; ntr, trifacial nerve. {Loch, with permission.) 

(c) Recocainize in order to insure anesthesia of the deeper tis- 
sues. A few minims of a one-half of 1 per cent, cocaine solution, 
administered hypodermatically into the submucosa of the upper portion 
of the lateral nasal wall and into the soft tissues covering the 
ethmoid, insure the local anesthesia. 

( d ) As a rule the removal of the middle turbinal brings into direct 
view one or more open and discharging cells, which serve as a point of 
entry for the ethmoidal operation; otherwise, the anterior ethmoidal 
cells should he located and outlined, the bulla ethmoidalis being the 
distinctive mark. The cells should then be entered, preferably by 
means of a sharp, slightly curved curd, and an opening made of 
Sufficient size to enable a thorough exploration with a probe. Con- 



618 NOSE AXD NASAL ACCESSORY SINUSES. 

tinuing the operation, one cell after another is entered and all polypi, 
edematous tissue and debris of bone removed with the curet or 
the Grunwald forceps. 

The chief dangers to be feared are injury to the brain or accidental 
entrance into the orbit. The forceps above recommended for removing 
the cells occupying the upper plane of the ethmoidal labyrinth pos- 
sess the advantage both of efficiency and safety. Under no cir- 
cumstances should sharp cutting or drilling instruments be vigor- 
ously employed in the region of the cribriform plate or the orbital 
plate of the ethmoid. Ballenger advises the removal of the eth- 
moidal labyrinths en masse by means of strong, sharp, cutting 
instruments. The first incision cleaves the entire labyrinth from its 
attachment to the upper (cranial) wall. Then follows a second 
sweeping incision which cleaves the remaining labyrinthine attach- 
ments from the orbital plate. The author cannot commend this 
operation as a rountine procedure and he believes that, in any exten- 
sive series of cases operated upon by this method, serious intra- 
cranial or orbital complications would occur with greater frequency 
than would ensue when the more simple method is employed. 

After completing the removal of the anterior group of cells, the 
operator should calculate the probable location of the cells of the 
posterior group. (See Fig. 407.) 

At a distance not greater than 2 centimeters from the original open- 
ing into the anterior group, the posterior cells are encountered. They 
lie directly behind, and. as a rule, in a plane slightly lower than the 
anterior group. Hence the excavation should be continued into this 
group, providing the diagnosis of empyema has previously been made. 
The posterior cells are approached by extending the operation 
directly through the already open anterior cells, and their walls 
should be entered and broken down in exactly the same manner. 
These cells occupy an anteroposterior space of about 1 centimeter, 
and less danger attends their removal than is incurred while operat- 
ing upon the anterior cells. 

It is important that all shreds of diseased membrane, spiculae 
of bone and polypoid tissue should be removed and the denuded 
surfaces smoothed off as a final step in the actual operation. 

Often the operation is tedious and prolonged on account of the 
hemorrhage and the consequent difficulties of inspection, and many 
operators prefer repeated sittings under local anesthesia, whereby 
the hemorrhage is more controllable and the field more accessible 
for visual examination. 

Complications. — The intranasal method of operation is occasion- 
ally followed by troublesome emphysema involving the orbit and 
eyelids, as a probable result of the/forcible entrance of air through 
an accidental opening, or a pre-existing necrotic sinus through the 
orbital plate of the ethmoid bone. The above complication super- 
venes almost immediately upon the completion of the operation. 
From the same source infection and abscess of the orbit may follow r . 
In the same manner injury to and infection of the meninges tran- 
spires. It is contended by some observers that intracranial compli- 



THE ETHMOIDAL SINUSES. 619 

cations may be induced by the shock and irritation of the operation 
alone. In a limited proportion of cases of purulent ethmoiditis 
there is a pre-existing" latent meningitis or a circumscribed brain 
abscess, either of which may be excited to renewed activity by the 
manipulations incident to the operation, especially when carelessly 
or unskillfully performed. 

3. Complete Removal of One or Both Groups by the Ex- 
ternal Route. — In the external operation the ethmoidal labyrinth may 
be reached in three ways — viz., (a) The direct route, (b) Combined 
with the external operation upon the frontal sinus, (c) The maxillary 
route. 

Of these the first named only is employed for purulent disease 
which is limited to the ethmoidal cells. The method of entering 
the ethmoidal labyrinth directly is depicted in Fig. 400. 

By the direct route the ethmoidal labyrinth is entered through 
that portion of the nasofrontal region directly anterior to the cells, 
the primary curvilinear incision being made midway between the 
median line and the inner canthus of the eye, and extending from a 
point just below the eyebrow near the supraorbital notch to a point 
about jA inch beneath the level of the inner canthus. The soft 
tissues, including the periosteum, are then retracted and all bleed- 
ing vessels tied off. When a fistulous opening is found it serves as 
a point of entrance to the cells, otherwise by means of a chisel a 
portion of the nasal bone and of the frontal process of the superior 
maxilla is resected, through which the labyrinth is reached. The 
opening may be gradually enlarged by careful removal of a suffi- 
cient portion of the external bony covering, always using care to 
avoid the orbital plate externally and the cribriform plate above. 
The space is sufficient to permit a comparatively large external 
bony opening through which even the deeper cells may not only 
be explored, but thoroughly curetted. 

The removal of the middle turbinal is a necessary step in the 
external operation. Hemorrhage into the pharynx is prevented 
either by tamponing the nares after the manner heretofore advised 
for the Killian operation or by means of a large tampon retained in 
the epipharynx by suitable forceps. Aided by direct illumination 
from a well-adjusted headlight (Fig. 5) it is possible to maintain 
continuous illumination of the operative field. The anterior eth- 
moidal cells are first broken down and removed. Again, the Briin- 
ings forceps (Fig. 401) are recommended as the safest and most 
effective instrument for engaging and removing the diseased soft 
tissue, and the thin walls of the cells. A liberal portion of the floor 
of the frontal sinus may also be removed at this operation if con- 
sidered necessary. Continuing the operation the posterior cells 
should likewise he excavated and the spheni lidal sinus when di eased. 

This method of entering the sphenoidal cavity is feasible and 
by many authorities is considered preferable to all others. In case 
the operation is to be confined t" the ethmoidal c !ls, the final 
steps of the operation consist of packing the denuded cavity with 
sterile gauze and closure of the external wound. After parking the 



620 NOSE AND NASAL ACCESSORY SINUSES. 

cavity with one long strip of gauze, the distal end of the section of 
gauze should be carried well down into the nasal cavity in order 
that the packing may subsequently be removed through the anterior 
nares. The external wound is then closed with sutures, which 
should unite both the skin and the denuded periosteum. 

(b) Whenever empyema of the frontal sinus is combined with 
the ethmoiditis and the double operation is necessary, the combined 
operation (Killian) described in Chapter XXXVIII becomes feasi- 
ble. Under these circumstances it is customary first to complete 
the operation upon the frontal sinus, after which the ethmoidal cells 
are reached through the floor or lower part of the inferior wall of 
the former (Fig. 400). The floor of the frontal sinus furnishes a 
guide to the upper surface of the ethmoidal cells. 

(c) A third method of procedure is the antrum route, in which 
the cells are entered by breaking down the lamina of bone between 
the maxillary antrum and the anterior ethmoidal labyrinth. By 
this same method the sphenoidal cavity may also be reached. 

Whenever orbital abscess is present care should be taken to 
curet the entire pus canal, and especially the portions of the 
necrosed orbital plate. The same holds true when the cranial table 
of the ethmoidal labyrinth is necrosed. In the latter it is preferable 
to expose a considerable area of dura and thus secure free drainage, 
in addition to the complete removal of all diseased areas of necrosed 
bone. 

After-treatment. — Thorough surgical removal of the ethmoidal 
cells and all surrounding diseased tissue should put an end to the 
purulent process. As soon as the operation is completed the patient 
should be placed in bed. Edema about the eyelids should be con- 
trolled by the application of ice-cloths. The primary dressings 
should be removed about the third day. During a few days sub- 
sequent to the operation the lining of the nasal cavity in the vicinity 
of the ethmoidal cells is liable to undergo marked infiltration, a 
phenomenon of reaction on the part of the mucosa and periosteum 
which disappears in a short time of its own accord. It is doubtful 
whether continuous packing with gauze strips is advisable. Upon 
each redressing the wound cavity should be cleansed with sterile 
saline solution introduced either by means of douche or spray, under 
mild pressure, always avoiding violent blowing of the nose in order 
to prevent the entrance of infection into the middle ear. At every 
dressing it is advisable to remove any shreds or spicule of bone 
which may have been overlooked. 

The granulations when healthy should be allowed to grow 
unmolested, but unhealthy and exuberant granulations may be 
reduced by applications of nitrate of silver, chlorid of zinc, or, best 
of all, by curettage. From this time on free drainage and cleanli- 
ness, together with control of granulations, should be the keynote 
in the management of the case. The patient should be taught to 
carefully cleanse the nasal cavities in order to insure continuous 
cleanliness of the parts. The after-treatment is always consider- 
ably prolonged and tedious both to the patient and to the operator, 
but its importance is usually justified by the results obtained. 



THE SPHENOIDAL SINUSES. 621 

II. THE SPHENOIDAL SINUSES. 

Surgical Anatomy.— The middle portion of the body of the 
Sphenoid bone is occupied by two cavities known as the sphenoidal 
sinuses, which are separated from each other by a septum. Each 
cavity opens into the corresponding naris, by the ostium sphenoidale. 
The sphenoidal cavities are not present at birth, but begin to develop 
after the seventh year. The dividing wall projects outward upon 
the anterior surface of the bod}^ of the bone, where it is designated 
as the sphenoid rostrum. This rostrum forms the posterior and 
uppermost portion of the nasal septum. The upper part of the 
sphenoidal septum is commonly asymmetrical to such an extent that 
one cavity may be three or four times larger than the other, and 
occasionally the septum is partially or wholly absent, in which event 
the two sinuses form one large cavity (Fig. 408). Under normal 
conditions the size of the sphenoidal sinuses is in inverse ratio to the 
thickness of their bony walls; hence a large sinus usually has 
extremely thin walls. The ostium or sphenoidal opening is located 
in the upper portion of the anterior sphenoidal wall rather close to 
the septum. It is invisible in the living subject, unless in atrophic 
rhinitis cases or after complete removal of the middle turbinal bone. 
It lies in the sphenoethmoidal recess. The level of the sphenoidal 
ostium is variable, however, as compared to the floor of the cavity. 
As a rule the orifice is placed above the middle of the anterior wall. 

The walls may be described as a roof, which is a portion of 
the floor of the anterior cerebral fossa; the external wall, which is 
thin, separating the cavity from the cavernous sinus or the internal 
carotid artery and portions of the third, fourth, fifth and sixth 
cranial nerves, which lie between it and the dura; the internal 
(mesial) wall, which is the septum already described, and the floor, 
which is formed by a substantial portion of the body of the sphenoid 
bone. The relation of the nasal accessory sinuses, and particularly 
of the sphenoidal sinuses to the optic nerves (Fig. 406) is of con- 
siderable clinical importance. Loeb 1 has written an exhaustive 
thesis upon this subject, to which the reader is referred for details. 

The anterior zvall in its superior portion is composed of the 
posterior ethmoidal labyrinthine wall, and its remainder forms the 
nasosphenoidal partition and contains the ostium sphenoidale. 
Occasionally a small portion of the anterior wall forms a part 
of the orbit. Small accessory sphenoidal sinuses are occasionally 
present, being located in the lesser wings. According to Loeb, in 
bone sections the sphenoidal sinuses in the anteroposterior di- 
ameter vary from 2 to 42 mm.; superoinferior, 4 to 36 mm. ; lateral, 
2 In 35 mm.: averaging, respectively, 21.5, 22.8 and 18.4. The 
sphenoidal sinuses are sometimes entirely absent, and bony ridges 
and circumscribed excrescences are more common than m the re- 



1 "A Study of tlic Anatomic Relations of the Optic Nerve to the Acces- 
sory Cavities of the Nose," Transactions of the American Laryngological, 
Rhinological and Otological Society, 1909. 



622 XOSE AND XASAL ACCESSORY SINUSES. 

maining accessory sinuses. The mucous lining- of the sphenoid 
sinuses forms at the same time the periosteal covering similar to 
that of the ethmoidal labyrinth (Hajek). 

Pathological Anatomy.— The pathological alterations which 
invade the sphenoid sinus are: 1, changes in the bone, and, 2, inflam- 
matory changes involving the lining mucosa. The changes in the 
bone commonly arise from a cortical osteitis which has originated 
in the mucosa of the sphenoidal sinus. The more destructive 
processes (caries) which involve the bony walls of the sphenoidal 
sinus are almost exclusively of syphilitic origin, but at times a 




Fig. 408. — Front view of a slightly slanting coronal section of the 
skull. The slant is downward and forward, and shows the posterior 
wall of a large single sphenoidal cavity, also the posterior ethmoidal cells. 
The lower larger opening is the nasal opening into the pharynx, on both 
lateral walls of which the pharyngeal orifices of the Eustachian tubes are 
seen. Below, the soft palate comes into view. With key plate. 

tuberculous process affects this region. It is a mooted question 
whether this condition constitutes a direct pressure necrosis for 
which the pent-up pus is responsible, or whether it is due to an 
intermediate thrombophlebitis. Rupture of the walls of the 
sphenoid sinus may open up a pathway of infection into the nose, 
the orbit or the meninges. 

The lining membrane of the sphenoidal sinus is less susceptible to 
inflammatory changes (hyperplasia) than the other accessory sinuses. 
In most cases of acute inflammation the mucosa becomes red, injected 
and slightly edematous. When severe the edematous infiltration is 
much increased, and secretion is profuse. Occasionally ecchymosis, 
with a bloody secretion, may be observed. Many observers contend 



THE SPHENOIDAL SINUSES. 



623 



that even in severe acute inflammations of the sphenoidal sinuses the 
nasal mucosa may remain normal, the observation being interpreted as 
indicating the independent character of the inflammation, in contra- 
distinction to its being transmitted from the mucous lining of the nose. 

The changes incident to chronic inflammation of the sphenoidal 
mucosa are believed to correspond in every part to those observed in 
connection with the other accessory sinuses of the nose. There is, 
however, less tendency to the formation of polypi and cysts, the 
pathological changes usually being confined to thickening, hyper- 
trophy and sclerosis of the mucosa. 

Method of Examination. — After wiping or spraying the accumu- 
lated secretions from the superior meatus, the tissues should be anes- 
thetized and contracted by means of cocaine and adrenalin. Zucker- 

Ur&e Single 

.SPHENOIDAL CAVitY* 




rue PHARYNX 



Key plate for Fig', 4 r »S. 



kandl has outlined the most accurate method to be followed in 
reaching" the sphenoidal sinus. A probe (.Fig. 409) following the 
continuation of a line connecting the inferior nasal spine with the 
middle of the free margin of the middle turbinal will strike the 
anterior wall of the sphenoidal sinus, and. in a few favorable cases, 
the sphenoidal ostium itself. The ostium is not always so readily 
reached, since it does not invariably occupy the same level. Another 
reason for failure to enter the ostium is due to the difficulty in 
invariably directing the sound over the exact geometrical centre of 
the turbinal. Furthermore it is impossible to enter the sphenoidal 
ostium when the middle turbinal is enlarged. In the majorit} of 
cases the ostium is not visible by rhinoscopy; nevertheless often il 
is possible to enter and to explore the sinus even though the orifice 
remains invisible. In the absence of the middle turbinal the ostium 
is plainly visible. 

If the point of the sound is slightly curved outward it is more 
likely to enter the ostium. Upon entering, the point of the sound 
first should be curved downward to prevent its impact against the 



624 NOSE AND NASAL ACCESSORY SINUSES. 

roof of the sinus in case the ostium is situated at the highest part of 
the anterior wall. 

When the probe is in the sphenoidal sinus its movements in every 
direction become restricted by the limited diameter of the ostium. 
Additional evidence is obtained by determining the distance between the 
inferior nasal spine and the anterior wall of the sphenoidal sinus. In 
the adult, according to Hajek, the measurements average from 6 to 8 
centimeters, varying only within narrow limits, according to the age 
of the patient and the conformation of the skull. That an entrance has 
been effected may be determined whenever the sound enters 7 x / 2 
to 8 centimeters in an individual with a small head, or 8>V 2 or more 
centimeters in large ones. Occasionally it may enter a distance of 
9y 2 to 10 centimeters, especially when the distal end of the instru- 
ment has been turned downward, in cases where the longitudinal 
diameter of the sinus amounts to from 2 to 2>y 2 centimeters. 




Probe in sphenoidal sinus. 



DISEASES OF THE SPHENOIDAL SINUSES. 

Having considered the pathology of purulent diseases of the 
sphenoidal sinuses and the method of examination of these cavities, the 
symptoms, course and treatment of these affections are briefly 
outlined under two general subdivisions, as follows : — 

(a) Acute empyema ; 

(b) Chronic empyema. 

The etiology of empyema of the sphenoidal sinuses is so similar 
to that already defined in similar affections of the neighboring accessory 
sinuses of the nose that it is not repeated here. Nevertheless a few 
slight variations are enumerated as follows : — 

1. Closed empyema is less common in the sphenoidal sinuses. 

2. Excessive outgrowths of edematous polypi from the lining 
mucosa are infrequent. 

3. Purulent involvement, both acute and chronic, is proportionately 
less common than in the neighboring sinuses. 



THE SPHENOIDAL SINUSES. 625 

4. Empyema of the sphenoidal sinuses is prone to occur con- 
currently with a like process in the posterior ethmoidal cells. 

Symptoms. — The subjective symptoms of empyema of the sphe- 
noidal cavities are extremely inconstant and unreliable. They con- 
sist essentially of, 1, headache; 2, disturbances due to abnormal 
secretion ; 3, interference with the sense of smell ; 4, vertigo. 

The objective symptoms are, 1, the localization of the secretion in 
the nose and nasopharyngeal space; 2, the secondary changes in the 
lining mucosa ; 3, the findings resulting from rhinoscopy and sounding. 

Pain is not constant and may be absent altogether. The head- 
ache commonly is located at the base of the brain, the postorbital 
region, or in the region of the nasopharynx. Vertigo is of com- 
paratively common occurrence, of varying intensity, and may either 
be constant or intermittent. Whenever, as a result of the purulent 
process, destruction of the bony walls of the sinuses ensues, dangerous 
sequels are likely to occur. Briefly enumerated, the complicating 
lesions are meningitis, brain abscess, thrombosis of the cavernous 
sinus, paralysis of the ocular muscles, and sudden blindness. Even 
closed empyema has been known to produce paralysis of the ocular 
muscles, protrusion of the orbit, and sudden blindness. The affection 
so rarely exists uncomplicated by disease of the other accessory sinuses, 
notably the ethmoidal labyrinth, that great confusion is encountered 
in differentiating the symptoms. 

The most prominent and constant symptom is the discharge 
which flows backward over the pharyngeal vault, and either escapes 
into the larynx or forms into crusts upon the posterior end of the 
middle turbinals, where it gives rise to irritation, to relieve which 
the patient ''hawks" almost incessantly. In uncomplicated cases 
the secretion is observed in front of the olfactory fissure, but is 
more profuse posteriorly in the nasopharynx. The amount of 
secretion in sphenoidal empyema varies, depending upon the stage 
of the disease, its extent, and the size of the sinus. In chronic cases 
the sense of smell is materially lessened. 

Prognosis. — In acute cases and in the majority of chronic 
ones, in individuals who submit to proper treatment the prognosis 
is good, the chief dangers arising from extension of the necrotic 
process to nearby structures. 

Treatment. — In the treatment of the sphenoidal sinuses the 
following difficulties are encountered : — 

1. The middle turbinal, particularly when enlarged, forms a 
barrier both to direct inspection and to instrumentation. 

2. A deflected or thickened septum may encroach upon the 
lumen of the meatus of the affected side. 

3. Extensive ethmoiditis, accompanied with polypi which fill 
the middle meatus. 

These barriers do not exist in rases of extensive atrophic 
rhinitis wherein the middle turbinal has disappeared, or when (lie 
anterior portion of the ethmoidal labyrinth together with the 
middle turbinal have been removed. 

Having ascertained that the sinns is the seat oi pus, the 

10 



626 N< >SE AND XASAL ACCESSORY SINUSES. 

simplest method of treatment, one that is applicable in acute cases, 
is by means of irrigation. A Myles sphenoidal cannula (Fig. 410) 
or an ordinary Eustachian catheter bent to a proper curve is intro- 
duced through the sphenoidal ostium and the sinus is cleansed with 
warm physiological salt solution. Before removing the cannula, 
air should be blown into the cavity in order that no residual secre- 
tion shall remain. In case the discharge persists a small amount of 
a 2 per cent, solution of silver nitrate or of a 25 per cent, solution of 
argyrol may be instilled into the sinus every second or third day, 
to be washed out after remaining from thirty to sixty seconds. 

Whenever the irrigations fail to arrest the discharge, it becomes 
apparent that the lining mucosa of the cavity is the seat of hyperplasia 
and possibly of polypoid degeneration; hence the drainage must be ac- 
celerated and the polypoid excrescences removed. For this purpose 
surgical measures arc necessary, both for the enlargement of the open- 
ing into the sinus, and for the removal of any diseased mucosa or bone. 
(For description of suction treatment see page S77.) 

Surgical Treatment. — Three general types of operation are em- 
ployed : 1, the artificial enlargement of the sphenoidal ostium; 2, the 



=00 



Fig. 410. — Myles's sphenoidal cannula. 

making of a new orifice in the anterior wall of the sinus, irrespective 
of the normal opening; 3. the radical procedure whereby the entire 
anterior wall of the cavity is removed, together with thorough curette- 
ment of the lining mucosa and the diseased osseous walls. Any opera- 
tion upon the sphenoidal cavity performed by the nasal route presup- 
poses a preliminary removal of the middle turbinal. Previous removal 
of the ethmoidal labyrinth also greatly facilitates the operation upon 
the sphenoidal sinus. The intranasal route is preferable to any form 
of external operation, and the latter is feasible and advisable only in 
conjunction with external operations upon the ethmoidal labyrinth.- 

In operating upon the sphenoidal sinus by the nasal route local 
anesthesia is to be preferred, inasmuch as the upright position and 
better control of hemorrhage enables the operator to view each step of 
the operation. A 1 : 5000 solution of adrenalin should be sprayed over 
the upper and posterior areas of the nasal cavities, for the purpose of 
enlarging the field of observation and to control the hemorrhage. A 
few drops of a 4 per cent, solution of cocaine may be instilled into the 
sphenoidal cavity. Medgets of cotton soaked with the same solution 
should be packed over the anterior wall of the sphenoidal cavity and in 
the middle meatus. Fully twenty minutes should he allowed for local 
anesthesia to take place. 

1. Simple Enlargement of the Osteum. — This is accomplished 
by introducing a curet which is slightly larger than the ostium and 



THE SPHENOIDAL SINUSES. 627 

forcibly breaking down its borders. Further enlargement is 
obtained by the use of some form of punch or biting forceps (Fig. 
411). This procedure may be followed by a period of irrigation 
after the manner described in the foregoing paragraphs. It often 
is possible to instruct the patient to irrigate his own sinus. 

2. Perforation of the Anterior Wall of the Sphenoidal 
Sinus. — This procedure is advocated by many authors in extending an 
operation from the posterior ethmoidal cells. A strong but small- 
sized curet is introduced into the nasal cavity in an upward and 
backward direction, and at an angle of 45° to the nasal floor, until it 
comes in contact with the anterior sphenoidal wall, through which 
it is forced. From this point of entry the opening should be 
enlarged by punching out sections of the anterior wall. Through 
this opening the sinus may be explored and curetted if necessary. 




SS^=V 



Fig. 411. — Sphenoidal punch 

forceps. 



3. The Radical Operation. — The term radical operation in this 
connection implies the removal of the anterior wall of the sphe- 
noidal sinus and the curetment of all polypoid tissue, diseased 
mucous membrane and necrosed bone when present, preferably by 
the intranasal route. Having removed the posterior ethmoidal cells 
and the middle turbinal, entrance is made through the ostium 
sphenoidale, or by puncture of the anterior wall (see former para- 
graph). Then with a forceps (Fig. 411) and a sharp curet the 
remaining portion of the osseous wall is removed piece by piece. 
With bright illumination a good rhinoscopic view of each step of 
the procedure is i ibtainable. 

Having removed the anterior wall the interior of the sinus 
should be inspected and probed. If the mucous membrane is 
edematous with polypoid excrescences il should be subjected to 
vigorous curetment, always bearing in mind thai the procedure is 
not devoid of danger if the outer lateral wall is broken through. In 
a considerable proportion of cases the polypi are confined to the 
areas surrounding the orifice, in which event the more healthy 
mucosa should remain undisturbed. 



628 NOSE AND NASAL ACCESSORY SINUSES. 

The final step of the operation consists in washing all mucus 
and shreds of bone and tissue from the sinus cavity, after which it 
should be lightly packed with a strip of iodoform gauze. On the 
following day the gauze may be removed and the wound irrigated 
with a warm saline solution. The further treatment consists in 
daily irrigation and the prevention of contraction and partial closure 
of the wound by exuberant granulations. It is often necessary to 
apply a 2 to 5 per cent, nitrate of silver solution every second or 
third day about the opening of the sinus in order to prevent con- 
traction, until finally a permanent ample orifice is secured. A recur- 
rence of polypi demands a secondary curetment and packing with 
gauze for a few days. 

The results as a rule are satisfactory and the secretion ceases 
in a short time. Other cases prove to be refractory and recovery 
i^ protracted. In the protracted cases considerable annoyance is 
occasioned by the retention of scales and crusts. 

External Operations. — The preliminary steps of the external 
operation through the ethmoidal labyrinth are described in the 
section on the Ethmoidal Sinuses. 

After the excavation of both the anterior and posterior eth- 
moidal cells is completed, the sphenoidal sinus is entered by break- 
ing through the anterior wall. The wall separating the sphenoidal 
cavity from the posterior ethmoidal cell is extremely thin and some- 
times it has already broken down. Griinwald- states that 73 per 
cent, of his cases of sphenoidal sinus affections were complicated 
with disease of the posterior ethmoidal cells. Here cutting forceps 
or a curet, used with care, forced through the posterior ethmoidal 
wall, may easily enter the sphenoidal cavity, which may then 
properly be explored, flushed with proper solutions, or even packed 
with gauze ( Eig. 400). 

Jansen has advocated a method of approaching the sphenoidal 
cavity through the antrum of Highmore, the latter cavity being 
entered through a large opening in the canine fossa. 

Tne ethmoidal cells are first entered at the inner and upper angle 
of the antrum, the direction being inward, backward and upward. 
Following the same direction the sphenoidal sinus is reached. 
Onodi has shown by measurements of skulls that the Jansen pro- 
cedure is impossible in man}- cases, and furthermore it is not devoid 
of danger. There is no tangible advantage in the external opera- 
tions over the intranasal procedures above described; hence they 
are not commended. 



2 Rapport presente a l'Assoc. medic, britannique a Manchester, Juillet, 
1902. 



CHAPTER XL. 

THE CORRECTION OF EXTERNAL NASAL DEFORMITIES, EPI- 
STAXIS, FOREIGN BODIES IN THE NOSE, PARASITES IN 
THE NOSE, RHINOLITHS, NASAL FURUNCULOSIS. 

External nasal deformities are characterized either by absence, 
in whole or in part, of the normal anatomical structures of the nose, 
or else an exaggeration of its natural contour. The intranasal 
deformities, usually of the septum, which are commonly concerned 
with the changes in the external shape of the nose, have been 
described in Chapters XXXV and XXXVI. 

The common varieties of nasal deformities are: (a) the crooked 
or twisted nose; (b) the hooked or beaked nose; (c) the "saddle" 




Fig. 412. — A twisted nose. 



nose; (d) the flat nose; (e) the broad-bridge nose; (/) the pinched 
nose; (g) the "pound" nose; (h) partial or total absence of nose. 

(a) The most common deformity of the nose is the crooked or 
twisted nose, bent to either side of the median line (Fig. 412). This 
type of external nasal deformity is caused: 1, by congenital 
asymmetry; 2, by external violence resulting in fracture of one or 
both nasal bones (Fig. 413), or fracture or dislocation of the bony 
or cartilaginous septum ; 3, by disease of the soft parts ; 4, by tumors. 

(b) The hooked or beaked nose is really an exaggerated form 
of the so-called "Roman" nose, which naturally has an arched con- 
tour when seen in profile in contradistinction to the "Creek" nose, 
which presents a straight profile. The hooked nose is often asso- 
ciated with a heightening of the palatal arch, which causes the 
superior maxillary hones to recede, in consequence of which the 
nasal hones becomes more prominent. An unduly high palatal arch 
is either congenital or due to mouth-breathing and obstructed nasal 
respiration, brought about by a lymphoid hypertrophy or adenoids 
in the nasopharynx. Deflections of the bony or cartilaginous 
septum rarely are absenl in these cases. 

(r) The deformity known as saddle-nose (Fig. 416) is quite 
common. 

(629) 



630 



NOSE AND NASAL ACCESSORY SINUSES. 



It is characterized by a depression or absence of the natural 
nasal arch, and is due to external violence or disease. Syphilis 
(tertiary), in the majority of cases, is responsible for the necrosis of 
the nasal bones and cartilages which results in a sinking of the nasal 
bridge. Tuberculosis, lupus, and cancer are less common causes. 
Since the submucous resection of the nasal septum has come into 
popularity a few cases of saddle-nose have been observed where this 
operation has been undertaken during the active stage of a luetic 
infection, or the deformity has resulted from negligent or unskillful 
submucous surgery. Necrotic breaking down of the septal nasal 
cartilage from abscess is another cause of saddle-nose. 

((/) The flat-nose deformity is usually due to direct violence; 
some eases are congenital, in which event there is either a defect or 
absence of some of the skeletal facial structures. 





413.— Dislocation of both nasal bones and transverse defle 
of the cartilaginous septum caused by external violence. 



(c) An opposite condition to the flat or saddle-nose is the broad- 
bridge nose, a rare condition in which the broadening and thickening is 
due to traumatism or intranasal inflammatory conditions, either of 
which can cause a periosteal inflammation with increased nutrition 
to the nasal bone and the nasal processes of the superior maxilla, 
resulting in an enlargement or spreading of the nasal bridge." 

(/) The pinched nose (collapse of the aire nasi) is a deformity of 
the ala cartilages proper, or else an atrophy of the muscular fibres sur- 
rounding these ; often cicatricial bands from previous ulcerative dis- 
ease cause permanent narrowing of the nostril. 

(g) Enlargement of the bulbous portion of the nose is often found 
in such skin diseases as acne rosacea, and in the "pound" nose of 
the Germans. This deformity is also present in some cases of 
rhinoscleroma. 

(//) Absence of the nasal appendage in whole or in part is due to 
the ravages of ulcerative diseases (cancer, lupus and syphilis), or 
else to criminal assault, and in semicivilized people it is inflicted as 
a penal measure, religious mutilation or brutality. It is included in 
the above list in order to complete the list of external nasal 
deformities. 



CORRECTION OF NASAL DEFORMITIES. 631 

Treatment. — Only within recent years has the rliinologist 
endeavored to devise efficient means of treatment for correcting- the 
more formidable deformities. At present the treatment is based either 
upon prothetic, surgical or mechanical principles, and often combines 
any or all of these measures in individual cases. The Germans, French 
and Italians for some years past have done excellent work by way of 
plastic facial surgery, using the flap grafting method in most cases. 
They derive the tissue either from the finger, arm or forearm, or else 
from the adjacent cutaneous surfaces.' 

This plastic method is particularly serviceable in the cases where 
the ulcerative processes of the diseases mentioned above have 
destroyed the cutaneous or musculocutaneous soft structures cover- 
ing the nose and its - surrounding areas. The reader is referred 
to works on general surgery for descriptive detail of these plastic or 
grafting operations. 

It need only be mentioned that, in the treatment of external 
deformities, the intranasal irregularities must be corrected either 
before or after the operation which is performed to relieve the 
external nasal deformity. The crooked or tzuisted and the hooked or 
beaked nose are treated either by the external method or by the 
intranasal subcutaneous method as practised by Roe. 

In operating by the external method, a vertical or curved inci- 
sion of varying length is made through the skin and the periosteum 
which covers the deformity and with an elevator the soft tissues are 
pushed to either side, thereby exposing the deformity, which is now 
reduced to the desired level either with a chisel or saw. The 
periosteum is then drawn over the denuded bone and closed by 
sutures of catgut, and a subcutaneous suture of catgut is used to 
close the external wound. With primary union an almost invisible 
scar results. This operation possesses the advantage of accuracy in 
technique and adequate asepsis. 

Roe's method is intranasal and consists in making the incision in 
the nostril beneath and anterior to the deformity so that the skin and 
periosteum can be raised from the deformity, the latter then being 
ablated and removed, or else utilized in building up the depressed 
portion in order to make the nose symmetrical and give it the desired 
shape. Roe says: "Except in very large noses, it is rarely neces- 
sary or desirable to remove any portion of tissue, or even bone, for 
there is generally a correspondingly depressed portion thai requires 
lilling up to give the nose the proper shape. Particularly is this the 
case where the cause of deformity is traumatic, -when we simply 
have a displacement rather than a destruction of tissue, which sli. mid 
be restored, so far as possible, to its former posi-tiot ." 

A slender knife or saw is used to reduce the deformity, and the 
technique is difficult to describe, since it must vary in any given case. 
Slowness and extreme care must be exercised in the operation, and both 
the surgeon and patient need great patience, often more than one 
operation being necessary. Roc classifies nasal deformities sche- 
matically as follows : — 



632 



NOSE AND NASAL ACCESSORY SINUSES. 

I >l FORTUITIES OF THE NOSE. 





1 

Bony portii 


hi 


1 )efleci 


ted 




Cartilaginou 


IS 1 >< > I ti.'ll 


Vertical 




Lateral 

&>atulated 


i 

Tip 




1 

Wings 


1 

.'on vex 


1 . mcave 


Excessive 

or 
deficient 
in tissue 


Deflection 

from 

median 

line 


1 1 

Collapsed Expanded 



In cases of saddle-nose or flat nose the deformities may be cor- 
rected by the injection of paraffin to round out or fill in the deficiency 
in the contour of the nose, as first employed by Gersuny, of Vienna, 
in 1900, or surgical means may be employed. 




Fig. 414. — Smith's paraffin sy 



The prothetic method of subcutaneous paraffin injections is much 
favored by the author. Harmon Smith has improved the original 
technique, thereby lessening the dangers and ill effects of the paraffin 
injections. Three cases of amaurosis due to thrombosis of one of 
the ophthalmic vessels have been reported, which undoubtedly were 
the result of disregarding the caution to make firm pressure at 
the root of the nose in order to prevent particles of the injected 
paraffin from entering the circulation, or of using liquid paraffin or 
paraffin of a low melting point. Usually the remaining ill effects 
are abscess formation or sloughing due to infection at the site of 
injection, or to the poor constitutional condition of the patient who 
receives the injection. Patients who are victims either of syphilis 
in an active stage, diabetes or nephritis are unfavorable subjects for 
the paraffin operations. 

Smith advises the use of paraffin with a melting point of 115° F., 
which he obtains by adding sufficient petroleum jelly or the liquid 
petrolatum known as albolene to commercial paraffin melting at 140° 
F., to bring it down to 115° F. This may be injected cold, and hence 



CORRECTION OF NASAL DEFORMITIES. 633- 

reduce the danger of embolus formation. While many syringes 
have been devised for the paraffin injections, that of Smith (Fig. 
414) seems the most practical and is the one the author has used. 
It has a screw piston which allows the paraffin to be injected cold, 
and the amount can be controlled to the fraction of a drop. The 
cup (Fig. 415) is for the purpose of preparing the paraffin. Smith 
lays down the following mode of procedure : — 

Preparation of the Patient. — 1. The nose and adjacent areas 
should be scrubbed with green soap and water. 2. The area should 
then be scrubbed with alcohol. 3. The head is then covered with a 
towel dampened with a 1 : 5000 solution of bichlorid of mercury, and 
the arms and shoulders are covered with a sterilized gown. 

Preparation of Instruments and Operator. — Both the paraffin 
syringe, which is of metal, and the needle should be boiled. The 
paraffin, which comes in sterilized tubes, is again boiled in a metal cup, 




Fig. 415. — The paraffin cup. 

which can be placed in any sterilizer, the bottom of the cup being 
raised sufficiently to prevent the paraffin from scorching. The paraffin 
is drawn up into the syringe in a liquid state, after which the syringe is 
dropped into a receptacle of cold sterilized water, which soon 
solidifies it. The hands of the operator and his assistant should be 
sterilized. 

Methods of Injection. — No anesthetic is necessary, although some 
operators prefer cocaine locally injected. The injection of the cocaine 
is as painful as the paraffin injection. The patient should sit upon a 
stool of a height that, when the head is tilted backward, his nose is 
about on the level of the operator's elbow. The operator stands behind 
and to the left of the patient, and the assistant stands in front and 
slightly to the right of the patient. The assistant grasps the nose firmly 
with the balls of his thumbs pressed against the nasal bones, and with 
the tips touching only the root of the nose. In tin's way pressure is 
exerted along both sides of the nose and thus prevents the entrance of 
the paraffm into the areolar tissue around the eye, and also prevents it 
from entering the circulation, should the needle penetrate a small vein. 
The injection should be made from above downward, as this is the 
direction away from danger and toward nature's natural barrier, which 
is the adherence of the skin and cartilage of the tip and aire of the nose. 



634 NOSE AND NASA I. ACCESSORY SINUSES. 

Before introducing the needle, immerse it in hot water, and then 
give the piston several turns until the paraffin comes out in a hard 
cylindrical thread. The first few turns of the piston usually ejects an 
interrupted stream of paraffin mixed with oil and water, but, after a 
few turns, all the oil and water is expelled and the paraffin remains 
a solid block within the cylinder and needle of the syringe. 

At the point of injection, the skin should be lifted high with firm 
pressure and the needle introduced beneath the skin and into the areolar 
tissue above the periosteum. The point of the needle is made to 
penetrate to a point just beyond the depression, where the injection 




Fig. 416. — Photograph of a saddle-back nose, the result of 
external violence. 

is begun slowly and is continued as the needle is gradually with- 
drawn. It is advisable to stop the injection from time to time and 
mold the paraffin to meet the requirements of the case. Mean- 
while the needle is not withdrawn, but the syringe is held in place 
by an assistant. As a rule it is unwise to overcome the deformity 
with a single injection, but in many instances one injection proves 
sufficient. When anemia of the surface occurs, the injection should 
cease, as this is the danger signal that the tissue will stand no more. 
The needle should be carefully withdrawn, and the hemorrhage, 
if there is any, controlled with adrenalin, after which the puncture 
point should be sealed with collodion. The patient should be advised 
to rest in bed for the remainder of the day, and to apply ice-cloths to 
the surface of the nose. When the paraffin melts at 115° F. and is 
injected cold, it enters the tissue as a hard mass, and cooling sprays are 
unnecessary. 



CORRECTION OF" NASAL DEFORMITIES. 



635 



A second injection should not be made under one month, inasmuch 
as nature can do no more than care for the first injection during this 
time, and any additional demand might result in necrosis. 

In the author's opinion it is far preferable to inject too little 
paraffin -than too much at the first sitting, inasmuch as an amount in 
excess of the requirements not only creates a new deformity, but is 
more liable to be followed by ulceration or other serious reaction. 

Furthermore by injecting from above downward the paraffin is 
easily controlled and molded into its proper position with less danger 
of accidents. 




Fig. 417. — The saddle-back deformity, shown in Fig. 416, has been 
corrected by an injection of paraffin. 



A side-view photograph of a patient operated upon by tbe 
author by tbe paraffin method, in which the deformity was caused 
by external violence, is shown in Fig. 416. One injection proved 
sufficient to overcome the deformity (Fig. 417). 

Carter, in correcting depressed or irregular deformities of tbe 
nose, makes a mecbanical replacement by tbe use of a combined bridge 
and intranasal splint. The principle involved is mecbanical and 
rests on the reconstruction of the broken-down nasal arch, the intra- 
nasal splints "one acting from within the nose at the apex, and the 
other from tbe outside of tbe base," thus restoring the former sym- 
metry of a flattened nasal arch. Carter describes the apparatus and 
mode of procedure as follows: — 

"Tbe apparatus shown in Fig. 418 consists of a fenestrated steel 
bridge, the wings of which are connected by a hinge, and the distance 



636 



NOSE AND NASAL ACCESSORY SINUSES. 



to which they can be separated is regulated by a thumbscrew. The 
edges of the wings are padded with rubber, and small holes near the 
edges permit the gauze padding to be stitched on. The second part of 
the instrument consists of two small, hard-rubber splints perforated 
1>\ four small holes. 




Fig. 418. — Bridge and intranasal splint for correcting depressed' 
deformities of the nose. (Carter, with permission.) 

"The application of the apparatus is as follows,' assuming that 
there is a recent depressed fracture, or, in the case of an old deformity, 
that the tissues have been thoroughly mobilized by a previous operation 
to be described later: No. 14 iron-dyed silk is passed through one 




Fig. 419. — Sectional view of splint and bridge in place. 
(Carter, with permission.) 



of the holes in the hard-rubber splint and knotted ; the other end is 
threaded into a large curved needle ; this is passed from within the 
nose through the cartilaginous dorsum just below its attachment to the 
nasal bones. This process is repeated on the opposite side. The 
bridge is then applied and the swings adjusted with the thumbscrews 
to give the proper support to the base of the nasal triangle. The 



CORRECTION OF NASAL DEFORMITIES. 



637 



sutures are then run through the fenestra in the bridge, correspond- 
ing vertically to their exit from the nose and drawn tight enough to 
lift the dorsum into its proper position. The sutures are then tied 
together over the hinge. There should only be sufficient tension to 
support the bridge. The diagram (Fig. 419) shows the bridge and 
splint in position. The splint rests partly under the nasal bone and 




Fk 



420. — Illustrating the mechanics of the intranasal splint and bridge. 
(Carter, with permission.) 



partly under the cartilaginous dorsum. The result of pressure 
and counterpressure keeps the apparatus in position ; it should be 
worn for ten days or two weeks. 

"The respiratory function of the nose is not interfered with after 
the first two or three days, and the patients do not complain of great 
discomfort while wearing the apparatus. It is better for the patient 




Fig. 4_'l. — The primar 
septal side of 



rision for dissecting a flap from the floor and 
mcitus. (Mackentv, with permission.) 



to remain in bed during the treatment, but if the bridge is anchored to 
the forehead with adhesive plaster he may sit up. 

"According to Treves, in uncomplicated fractures of the nose, there 
is fixation in eight days and bony union in two weeks. 

"The mechanics of the apparatus is shown in the diagram ( Fig. 
420). ./ represents the downward pressure applied to the base of the 
nasal triangle and is produced by the tension of the sutures passing 
through the dorsum of the nose; B shows the horizontal pressure under 
control of the thumbscrew. The resultant force — that actually applied 
at the base — is represented by a line, ( , bisecting the angle formed by 



638 



NOSE AND NASAL ACCESSORY SINUSES. 



A and B, and is the proper direction to support the hase of the nasal 
triangle. A combination of this downward and inward pressure 
applied at the base and the balancing upward pull at the apex of the 
nasal triangle when applied to a nose in which the bony framework has 
been mobilized will tend to construct a normal symmetrical organ. 
This I have demonstrated on the cadaver as well as on the living 
subject." 

The Carter operation is particularly applicable to cases where there 
is a tendency to broadening of the nose, owing to the spreading apart 
of the nasal bones. 

Plates of rubber, silver and aluminum, etc., have been introduced 
surgically under the skin of the nose to correct the depressed or saddle- 
nose deformity, but usually they meet with little success on account of 




Fig. 422. — The dotted line illustrates the backward dissection across 
along- the floor at the mucocutaneous junction. (Mackeiity, with per- 
mission.) 

the unavoidable sloughing which ensues. Each deformity is a 
law unto itself, and no particular method is applicable to all cases. 
Refined surgical judgment is required to meet with success in 
any given case. In the pinched-nose deformity, paraffin injections along 
the floor of the vestibule have been recommended in Germany. The 
paraffin acts as a splint when set and so holds the wing of the nose 
outward. 

The following operation for the pinched nose has been devised by 
Dr. J. E. Mackenty : "The operation aims to enlarge the anterior 
naris by lowering and widening its floor. This is done by dissecting 
up a flap (Fig 1 . 421) from the floor and septal side, extending the 
dissection backward beyond the ridge of bone which crosses the 
floor at the mucocutaneous junction (Fig. 422). 

"The bone ridge is then removed doAvn to the level of the meatal 
floor behind. All redundant tissue is chiseled away from the base of 
the septum with scissors and forceps ; all unnecessary tissue is removed 



CORRECTION OF NASAL DEFORMITIES. 



639 



from the flap, leaving only cuticle and mucosa. Then the flap is cut 
beginning high up on the septum and slanting backward to the floor 
(Fig. 423). This allows the flap to fall to the newly made floor, where 
it is stitched (Fig. 424). This leaves the denuded area (Fig. 424) on 
the septum, which reduces the subsequent contraction to a minimum. 
The air now freely passing through the lower portion of the nostril 
obviates the valve action of the alse nasi above." 

In the "pound" nose deformity good results have been reported 
from the use of the high-frequency current and electrolysis. Where 
the nasal appendage is entirely wanting a false nose of rubber or 
celluloid, flesh tinted and held in place with spectacles (Fig. 425), 
affords such patients much satisfaction and comfort. 




Fig. 423. — The flap has been 
dissected from the floor of the 
nostril. (Maekenty, with permis- 
sion.) 




Fig. 424. — The flap has been 
sutured to the line of the original 
incision. {Mackenty, with per- 
mission.) 



EPISTAXIS. 

Epistaxis or bleeding from the interior of the nose is due to 
a variety both of local and constitutional conditions. It is com- 
mon in children between the ages of five and fourteen, and rare 
during middle life. In old age it usually occurs as a result of some 
constitutional disease or local neoplasm. As a rule, when properly 
managed, nasal hemorrhage is not of serious import, except in 
hemophiliacs, in malignancy, or arteriosclerosis. According to Castle- 
bury, in 90 per cent, of all cases of nasal hemorrhage the scat of the 
hemorrhage is in the anterior portion of the nasal septum. 

Etiology. — The local causes of nasal hemorrhage arc chiefly 
as follows: 1. Traumatism from intranasal operations; injuries both 
direct and indirect — falls, blows upon the nose, stab-wounds, etc. 2. 
Defects of the cartilaginous septum; contact of the (lust-laden inspired 



air upon its 


convex surface, 


which 


n tun 


. '" 


oduces 


rritation and 


finally erosii 


ns and hemorrh 


ige. 3. 


Atn.pl 


lie 


•hinitis. 


Attempts to 


remove the i 


ispissated crusts 


in this i 


isease 


by 


picking 


the nose, are 


prone to pro 


luce erosions u] 


on the s 


'ptinn 


am 


turbina 


Is and subse- 


quent hemori 


hage. 4. Acute 


'hinitis. 


In se\ 


ere 


cases of 


acute inflam- 



illation of the nasal mucosa, hemorrhage is induced as a 



ilt of 



640 NOSE AND XASAL ACCESSORY SINUSES. 

excessive blowing of the nose. 5. Varicose veins in the septal mucosa 
are prone to attacks of hemorrhage, even upon slight injury, or when 
acutely inflamed. 6. The presence of foreign bodies and sequestra in 
the nasal cavities is attended with varying degrees of hemorrhage. 7. 
Tuberculous or syphilitic ulcerations and leprosy. 8. Malignant neo- 
plasms, sarcomata and carcinomata (see Chapter XLII). 9. Perfor- 
ating ulcer of the nasal septum. 10. Benign neoplasms, nasal polypi, 
fibromata, etc. 

Epistaxis is of general or constitutional origin, as follows: 1, 
Febrile diseases: chiefly nasal diphtheria, scarlet fever, measles, pneu- 
monia, typhoid and typhus fever, influenza, malarial and relapsing 
fevers. 2. Blood diseases: anemia, hemophilia, leukemia, purpura 
hemorrhagica, chlorosis, scorbutus, and chronic malaria. 3. Diseases 
of the heart and vessels : valvular lesions, cardiac hypertrophy. 
Bright' s disease, pulmonary emphysema,. etc. 4. Cirrhosis of the liver. 
5. The pressure of large tumors upon the blood-vessels of the neck. 
6. Violent exertion. 7. Temporary so- 
journ in extremely high altitudes. 8. Vi- 
carious hemorrhage from sudden sup- 
pression of the menstrual fluid. 

Diagnosis. — The diagnosis of nasal 
hemorrhage is based upon the appear- 
ance of a flow of blood from the anterior 
nares. Exceptions to this rule are found 
in those cases where hemorrhage which 
arises from the lungs, larynx, or 
pharynx, or from fractures of the cran- 
ial bones, flows from the nose. In 
patients recovering from anesthetics, or 
Fig. 425.— A false nose. who for other reasons remain in a supine 

position, especially upon the back, a con- 
tinuous backward flow of blood, from the nasal passages into the 
pharynx, may be swallowed and discovered only upon the appearance 
of subsequent attacks of vomiting. More specifically, the diagnosis 
depends upon the discovery of the actual seat of the point of bleeding 
within the nasal cavities. 

Treatment. — (a ) Local. In a majority of the simpler cases sud- 
den epistaxis is self-limited and no treatment is required. This is 
especially true of attacks which occur in young robust children. In 
cases of the above type the sudden attack is almost immediately fol- 
lowed by an equally sudden cessation of the flow of blood. Hence the 
loss of blood is immaterial. For some time subsequent to the attack, 
the patient should be advised against blowing the nose, or violent ex- 
ercise. Prolonged hemorrhage, without evidence of constitutional dis- 
ease or tumors, is usually amenable to local applications of adrenalin 
to the seat of the hemorrhage, or ice-packs placed upon the nose. 
Temporary pressure with tampons held tightly upon the bleeding point 
may control and terminate the hemorrhage. In severe cases a small 
syringeful of ice-water may be injected into the nostril, while at the 
same time the face is covered with a towel which has been immersed 
in ice-water, and the feet are immersed in hot water. Irrigations of 




CORRECTION OF NASAL DEFORMITIES. 



641 



hot water often are effective in controlling nasal hemorrhage. When 
due to a rupture of a septal blood-vessel and the attacks of hemorrhage 
are both frequent and prolonged, the bleeding vessel should be 
destroyed by means of an application of chromic acid fused, or by the 
galvanocautery puncture. The cautery point should be heated to a 
cherry red only. Hypodermics of human or horse serum are now 
being employed for the control of persistent hemorrhage, especially in 
hemophiliacs. Thrombokinase, locally applied to bleeding surfaces, is 
employed at the Manhattan Eye, Ear and Throat Hospital. 

Severe hemorrhages from blood-vessels which have been severed 
by intranasal operations, which do not subside in response to applica- 
tions of adrenalin or the cold pack, require some sort of continued 
pressure. A small piece of Bernay's sponge or gauze packing usually 
is effective. A strip of gauze immersed in a solution of acetotartrate 
of aluminum of 12 per cent, and inserted into the nares not only in- 
duces pressure, but acts as an astringent upon the bleeding vessel. 
Furthermore, the antiseptic quality of the solution preserves the 




Fig. 426. — The Belocq sound. 

tampon, so that it may safely be left in situ for from twenty-four to 
forty-eight hours. 

An available astringent to be applied is nitrate of silver in 5 to 20 
per cent, solution. Violent nasal hemorrhage, when due to serious 
constitutional causes, and when not amenable to the above-named 
measures, requires a combination of postnasal and anteronasal plug- 
ging as a last resort. For this purpose a Belocq sound (Fig. 426) is 
introduced through the anterior nares and its spiral portion ejected 
into the pharynx. To the distal end of the latter a thread is tied, and 
the sound gradually withdrawn with its thread attachment. A large 
tampon of absorbent cotton is then tied to the pharyngeal end of the 
thread, and the mass drawn upward into the epipharynx, and tightly 
against the choanje. The anterior nares are then tightly plugged. This 
method of tamponing the nose and nasopharynx produces extreme dis- 
comfort to the patient and often induces attacks of purulent otitis 
media. Hemorrhage induced by the presence of foreign bodies in the 
nasal cavities usually subsides quickly upon their removal. 

General Treatment. — Following a severe attack of nasal hemor- 
rhage, or recurrent attacks of epistaxis, especially when the loss of 
blood has been sufficient to produce extreme weakness rind anemia, an 
enema or an intravenous injection of a warm saline solution should be 
administered and the patient should remain in bed for several days or 
weeks, depending upon the gravity of the symptoms. Fresh air, nutri- 
tious diet, and the internal administration of iodin combined with 



642 NOSE AND NASAL ACCESSORY SINUSES. 

strychnia will hasten recovery. When due to grave constitutional dis^ 
eases, such as JJright's disease, cirrhosis of the liver, or to malignant 
tumors, epistaxis becomes a grave and troublesome symptom, and 
special measures must be employed for its relief. In case of malig- 
nant growths, cauterization or the entire removal of the neoplasm 
offers the best results, while individuals suffering from the above- 
named constitutional diseases should be referred to internists for ad- 
vice and treatment. 

FOREIGN BODIES IN THE NOSE. 

An almost endless variety of inanimate foreign bodies find lodg- 
ment within the nasal cavities. Young children are prone to insert 
small objects, such as shoe-buttons, pieces of cloth, peas, beans, seeds, 
hooks and eyes, pins, beads, etc., into the anterior nares. The most 
offensive foreign body which the author lias removed from a child's 
nose was a section of school sponge, which had been inserted three 
months previously. Insane persons and idiots seem to possess an inor- 
dinate fondness for filling the anterior nare with any small objects or 
masses which may be at hand. A distinct type of intranasal foreign 
bodies is represented by bullets, shot, pieces of shells, the broken tips 
of knives, dirks and stilettos, and explosives. Finally, foreign bodies 
may find access to the nasal cavities by way of the nasopharynx as a 
result of vomiting, eructations, or sudden sneezing or coughing while 
in the act of swallowing. 

Symptoms. — The symptoms are nasal hemorrhage (not con- 
stant), pain, nasal obstruction, dead voice, and, when the foreign body 
has remained for long periods, there is a unilateral, mucopurulent, 
fetid discharge, and excoriation of the borders of the nostril and upper 
lip. Upon examination the obstructive mass is observed in the nasal 
cavity. 

Diagnosis. — In addition to the history and symptoms above 
described, the diagnosis depends upon the exclusion of nasal polypi, 
tumors, sequestra of bone, and indurated ulcerations. Rhinoscopic 
examination, with bright illumination, preceded by an application of 
adrenalin to the nasal mucosa, and aided by the touch of a probe, usu- 
ally reveals the foreign body. 

Treatment.— The following directions are recommended for the 
removal of foreign bodies from the nasal cavities, viz., spray the nasal 
mucosa with a solution composed of cocaine, 4 per cent., and adrenalin, 
1 : 5000, twenty minutes before the operation. 

Under ample illumination and with the nostril widely dilated, 
grasp the object with strong forceps and carefully withdraw it. When 
the object has an oval smooth surface, pass a slightly curved ring curet 
or hook beyond the body, then tilt the handle upward and drag it out. 
In case a child is intractable, or an adult is hysterical or extremely 
sensitive, and in every instance when the foreign body is deeply in- 
serted or imbedded in the soft tissues or bone, the operation should be 
performed under general anesthesia. External operations are some- 
times imperative for the removal of large, deeply imbedded foreign 
bodies. 



CORRECTION OF NASAL DEFORMITIES. 643 



PARASITES (MAGGOTS, SCREWWORMS, FUNGI, ETC.). 

The nose is rarely the habitat of parasites in temperate or cold 
climates, but in tropical countries a considerable variety of parasites, 
such as maggots, screwworms and various fungi are found in the nasal 
cavities of the natives, especially those of filthy habits. From the 
cases reported by Goldstein, Foster and Steele, it would appear that 
larvce in enormous numbers hatch from the eggs which are deposited 
in the nasal cavities by certain flies, and, furthermore, that the offend- 
ing flies are usually attracted to the nasal cavities by the presence 
there of specific necrosis, ozena and similar affections. The screw- 
worm and maggots are the chief varieties. 

Symptoms. — The organisms give rise, to sensations of heat, itch- 
ing, pain and sneezing, and later to intense inflammation of the nasal 
mucosa, serosanguineous discharge, and, finally, in case they burrow 
into the tissues, to external swelling. 

Treatment. — The larvae must first be killed by injecting a dilute 
(25 per cent.) solution of chloroform into the nasal chambers, after 
which they should be removed by means of curet or forceps, and the 
nasal douche. 

RHINOLITHS. 

Rhinoliths generally depend upon some foreign body, which serves 
as a nucleus around which the concretion forms. 

Treatment. — When of small size and conveniently located, the 
removal of a rhinolith is a simple procedure. Under cocaine anes- 
thesia, aided by bright illumination, the mass should be grasped with a 
suitable forceps and withdrawn. Rhinoliths of large dimensions 
should be removed under general anesthesia. It is sometimes neces- 
sary to crush the mass and then remove the fragments piece by piece, 
in which event no portion of the rhinolith should be allowed to enter 
the larynx. 

NASAL FURUNCULOSIS. 

Furunculosis of the nasal cavities is characterized by the appear- 
ance of a circumscribed, painful swelling in some portions of the cuta- 
neous lining of the vestibule, which eventuates in abscess formation. 

Etiology. — They are caused by pyogenic micro-organisms, which 
gain access into the subcutaneous tissues through the hair follicles, the 
sudoriparous glands, or from traumatism. Picking the nose is a pro- 
lific source of this affection. They arc more commonly found among 
the ill-nourished and those who have become exhausted by overwork 
or disease. 

Treatment. — The abscess should he deeply incised, its contents 
scraped out with a small, sharp curet, and the cavity irrigated with a 
warm solution of boric acid or bichlorid of mercury, 1 : 5000. The 
subsequent treatment consists of cleansing alkaline sprays and applica 
tions of boroglycerid, 50 per cent., or ichthyol, 25 per cent., in order 
to prevent recurrence. 



CHAPTER XLI. 

NASAL NEUROSES. 

Two general types of nasal neuroses are herein considered: 1, 
sensory (neuroses of olfaction) ; 2, reflex neuroses. 

SENSORY (NEUROSES OF OLFACTION). 

The various types and degrees of sensory neuroses are classified 
as, 1, anosmia; 2, hyperosmia; 3, parosmia. 

ANOSMIA. 

Anosmia is the term commonly employed to define a partial or 
total loss of the sense of smell. 

Etiology. — Temporary anosmia is a common symptom of ordi- 
nary "cold in the head," in which event it is due to the swelling and 
engorgement of the intranasal mucosa and the consequent obstruction 
to the free access of air into the nasal passages. In the more severe 
types of intranasal inflammation, especially when due to grippe, measles, 
nasal diphtheria and scarlatina, the loss of smell may he prolonged and 
even permanent. 

Any form of prolonged nasal obstruction may cause impairment 
of olfaction. Nasal polypi, septal deviations, enlarged middle turbinals, 
tumors and extensive hyperplasia are the chief obstructive lesions con- 
cerned in impairment of the sense of smell. Certain nasal diseases, 
by interfering with the nerve endings, are prone to induce anosmia. 

The chief of these are atrophic rhinitis, purulent rhinitis, disease of 
the accessory sinuses, syphilitic and tuberculous lesions. Furthermore, 
anosmia may be induced by traumatism, noxious inhalations, and the 
use of harmful drugs. Usually it is bilateral, but it may be 
unilateral. 

Prognosis. — The prognosis is favorable except in cases where 
the anosmia is the result of deep-seated pathological changes in the 
mucosa, or to lesions involving the trunk of the olfactory nerve. In 
recent cases, when due to intranasal obstructive lesions, full recovery 
may be expected. 

Treatment. — The underlying cause should be determined and 
eliminated. 

Obstructive Lesions. — The treatment of obstructive lesions, the 
different forms of rhinitis, and of the affections of the nasal accessory 
sinuses has been fully defined in the foregoing chapters. 

The internal administration of strychnine sulph., gr. % , three 
times daily, and potassium iodid, gr. 15 to 30, daily, and local cleansing 
of the intranasal mucosa with bland alkaline solutions are measures 
deserving of commendation. 

HYPEROSMIA. 

The term hyperosmia is employed to denote a morbidly acute 
sensitiveness to odors, or, in exaggerated cases, to positive olfactory 
illusions. 
(644) 



NASAL NEUROSES. 645 

The affection is usually a manifestation of hysteria, neurasthenia, 
and sexual or menstrual disturbances. In the treatment of these cases 
the aim should be to correct the underlying cause. 

PAROSMIA. 

The term parosmia denotes a perversion or hallucination of the 
sense of smell. There are two general types of the affection — one a 
perversion of a normal odor, and the other a wholly imaginary odor. 
Both are usually most disagreeable (cacosmia) and evoke serious com- 
plaint on the part of the patient. It is a common hallucination among 
the insane, and occasionally is observed in epilepsy and hysteria. 

REFLEX NEUROSES. 

1, Hyperesthetic rhinitis (hay fever) ; 2, asthma; 3, nasal hydror- 
rhea ; 4, cerebrospinal rhinorrhea ; 5, epilepsy of nasal origin. 

HYPERESTHETIC RHINITIS. 

Synonyms. — Hay fever, rose cold, vasomotor coryza, catarrhus 
sestivus. 

This disease is commonly known as hay fever, hay asthma, June 
cold, rose cold, summer catarrh, etc. It is the chief of the respira- 
tory neuroses and occurs principally in patients of the neurotic type. 
It may be defined as an inflammatory condition of the nasal mucous 
membranes, usually periodical in its advent, appearing at yearly inter- 
vals and is characterized by a severe coryza accompanied with asthmatic 
symptoms. Extremely hyperesthetic areas on the nasal mucosa can be 
localized. 

Etiology. — This disease was well known in older medical 
times, but during the past century it has received much attention at 
the hands of both the general practitioner and the rhinologist, who have 
evolved many theories and speculations regarding its etiology. With- 
out recounting the numerous experiments carried out the etiological 
factors may be divided into the predisposing and the exciting causes. 

Tbe chief predisposing cause is a neurotic temperament which may 
either be acquired or the result of heredity. As a rule the affection 
is more prevalent among tbe refined and educated, who are under 
nervous and mental strain, than in the illiterate and poorer classes. 
That a psychologic element is predisposing to some degree is mani- 
fested by the fact that women, and usually those under forty years 
of age, are the more numerous subjects of this ailment. Exceptional 
cases have been reported during early child life and during old age, 
but the majority of cases occur in young adults. Topographic and 
geographic conditions play a role in its distribution; high altitudes 
being exempt from hay fever are much sought by these sufferers, 
and in the United States the disease is most prevalent in the eastern 
and western sections. Racial immunity seems to exist in the 
Asiatics and Africans. The climatic conditions in the United Slates 
that favor the disease most are prevalent during the summer and 



646 N< >SE AND XASAL ACCESSORY SINUSES. 

autumnal months; attacks rarely occur out of season. Personal idio- 
syncrasies, either subjective or else acquired by habits, are predispos- 
ing- to hyperesthetic rhinitis. In many cases pathological conditions 
of the nasal septum, turbinals, accessory sinuses are found or path- 
ological changes have taken place in their respective mucosa. Among 
the personal habits which predispose is the habitual use of narcotics or 
alcoholic stimulants. Furthermore, the infectious fevers and the 
gouty or rheumatic diathesis, with their accompanying or resultant in- 
flammatory conditions of the upper respiratory mucous membranes, 
are predisposing factors. 

Allergy and Pollen- therapy in Hay Fever. 1 — During the last 
few years, many investigations have been carried on to work out the 
relationships between the so-called Spring or Rose Fever and Hay 
Fever and the various pollens, and great progress has been made in 
the elucidation of certain facts hitherto unknown. 

In the light of these facts, the present classification of all these 
conditions should be as follows: Vasomotor rhinitis is a condition 
due to several general classes of causes. The causes usually found are : 
1. Nasal obstructions, etc., purely local in character. 2. Local bac- 
terial conditions in the nose, either acting locally or what is more 
probable, acting through diminished general resistance to the special 
organism or organisms in question. 3. General systemic conditions, 
due largely to the intestinal tract and being due basically to food or 
plant allergy. In this latter class are placed the above fevers and they 
comprise by far the larger class of cases coming under our observa- 
tion. Allergy to food and plants or what is better known as sensitiza- 
tion or anaphylaxis to foods and pollens has been known for years, 
but only recently, by the aid of modern serological methods have we 
been able to throw any light! on what actually occurs. 

The investigation of a large series of rose fever and hay fever 
patients with regard to their pollen protein sensitizations gives the fol- 
lowing general classification of cases. They fall roughly into four 
groups. 1. Those occurring in very early spring, and found to be due 
in most part to the early flowering trees and very early plants. This 
class is a very small one ; the course of the disease is very short and 
mild compared with the other classes, and very seldom is the physician 
consulted for the relief of the condition. 2. Those occurring in late 
spring, the ordinary rose fever or spring fever, and in our series 
due in large part to the ordinary grasses, June grass, vernal grass, 
sweet meadow grass, etc. It is surprising to find the small number of 
cases of this class that are due to roses. 3. Those due to the late 
spring 1 plants flowering in July. This is a very small class and almost 
negligible. 4. The large class due to the fall varieties and commonly 
known as hay fever. In our series, the causes run ragweed and 
goldenrod in most cases, Indian corn or maize in a few, and Cali- 
fornia privet in a considerable number, but usually in conjunction with 



1 Under the above caption the author presents the results to date of recent 
advances in knowledge of Pollen therapy, hased upon the experimental work of 
Dr. J. G. Dwyer, at the Laboratory of the Manhattan Eye, Ear, and Throat 

I lospital. 



NASAL NEUROSES. 647 

one or more of the first-named. Very often ragweed and goldenrod 
reacted in the same patient. 

The methods pursued in the investigation comprised the testing 
out of 'the patients for the anaphylactic reactions and then the thera- 
peutic inoculations with protein extracts. The tests are carried out ac- 
cording to the technique for the von Pirquet tuberculin reactions and 
the raw pollen is used as the antigen or exciting agent. The reaction 
takes place in about one-half hour and the readings of the intensity of 
the reactions are taken according to the same scale as in the Wasser- 
mann reaction. The patients are then inoculated with extracts of the 
various pollens to which they react and in strengths, roughly propor- 
tional to the skin reactions. It must be borne in mind, however, that 
the skin reaction does not always bear a direct relation to the severity 
of the disease. In our opinion, this is due to either or both of two 
factors: (1) the variation in the individual susceptibility, and (2) 
probably mostly due to variations in solubilities of the various pollens. 

The reactions are specific in nature and generally the skin re- 
actions become much less in degree or intensity, as the active immuni- 
zation with the protein extracts is carried on. In those so treated, a 
complement-fixation test is generally positive at some period or other 
of the' treatment and varies in degree with the immunizations. 

The great aims in the work are two. The first is to get a good 
active potent pollen protein extract, one that will keep under ordinary 
circumstances for a time. The other aim is to avoid anaphylaxis. 
With regard to the latter, it is absolutely essential to remember that 
no patient should be inoculated with a solution of a pollen to which 
he has not been found susceptible, as in principle such an inoculation 
might render the patient anaphylactic to this particular pollen and 
instead of doing good, harm would certainly occur. Hence stock pol- 
len extracts as a routine have no place here. Again, a patient re- 
ceiving doses of pollen extracts after once having received these ex- 
tracts some months previously might go into anaphylactic shock. 

The practical results are very encouraging. The results of treat- 
ment with the spring varieties have been more striking and more uni- 
form than with those of the fall varieties, this apparently being due 
to the more soluble character of the spring pollens. One striking fact 
is that a patient that is suffering from the spring varieties has never 
been found by us to be susceptible to the fall varieties; in other words, 
a patient suffering in the spring responds to the spring one only, and 
gives a negative reaction to the fall varieties and vice versa. Again, 
patients who complain of hay fever symptoms all the year around, in 
our experience have never been found susceptible to any pollen — in 
other words they fall into one or other of the other groups. 

Tt is a cardinal rule to follow to eliminate all other groups above 
before starting the inoculations. Loral obstructions tend to increase 
local congestion, and therefore favor the earlier onsel of sensitization. 

Pathology. — Other than the evidence of a catarrhal inflammation 
during the attack, no special lesion exists. The special hvpercslhctic 
aicas of the nasal mucosa are chiefly at either the anterior or posterior 
ends of the inferior turbinal bones and the adjacenl septal regions. 
and sometimes along the median portion of the middle turhinals. \1 



648 NOSE AND NASAL ACCESSORY SINUSES. 

these points the terminal nerve filaments are closer to the surface of 
the mucosa, either anatomically or else as a result of epithelial des- 
quamation. Hence, the exposure of the terminal nerve ends exposes 
them unduly to the excitants already mentioned. 

Symptoms. — Most cases occur in the summer and fall, and 
usually are repeated annually. The psychological element or that of 
associate ideas is strong, and such patients can predict to the day the 
time of onset of an attack. The usual symptoms, viz. : a severe 
rhinitis, itching of the nose, violent sneezing followed by a profuse 
watery discharge from the nostril, which often excoriates the lip, are 
met with in all cases. The turgescence of the soft parts blocks up 
the nose. Accompanying these nasal symptoms is a stinging and 
burning sensation of the conjunctiva, photophobia, lachrymation, 
puffing of the eyelids, with ocular or neuralgic pain chiefly in 
the back of the head. The nasal discharge later becomes muco- 
purulent, and at times a pseudomembrane forms which causes nasal 
bleeding upon its removal. The accessory sinuses possibly partake 
in this turgid condition of the mucosa, since the patients frequently 
have violent pain over the nasal bridge (ethmoid region) and over 
the frontal sinuses. Many have temporary loss of the sense of 
smell and taste, tinnitus aurium and temporary deafness from the 
extension of the catarrhal process to the Eustachian orifices and the 
nasopharynx. The system in general is involved by the interference 
in metabolism, by digestive and secretory disturbances, pyrexia and 
chills. Malaise and bodily prostration and mental hebetude have been 
known to accompany severe attacks. The onset is usually sudden, yet 
in some cases mild local premonitory symptoms arise. Asthma symp- 
toms occur in about one-half of the cases, usually the severer ones, 
probably as a result of the turgescence of the laryngeal and bronchial 
mucous membranes. The asthma may either accompany or follow 
the catarrhal symptoms and in some of the severer cases the attacks 
may eventuate in true asthma. During an attack of hay fever the hy- 
persensitive areas in the nose can be located with a probe. 

Diagnosis. — The periodic occurrence of the attacks along with 
the clinical picture as described is sufficient for a diagnosis. 

Prognosis. — The disease of itself is not fatal, and a small propor- 
tion of cases recover as a result of treatment. In others the disease 
disappears after the fortieth year. After a severe and prolonged 
attack the patient may easily acquire any critical ailment. 

Treatment (See Allergy and Pollen-therapy, page 646). — The 
constitutional dyscrasia or diathesis peculiar to the individual, whether 
gouty, rheumatic or neurotic, should receive careful attention and the 
proper hygienic regulations, diet and medicaments prescribed. The 
exhausting attacks of hay fever should be prevented if possible by 
advising the patient to seek a mountainous pollen-free region during 
the hay-fever season. Some patients find relief in a prolonged sea 
voyage. Dr. H. H. Curtis has proven by experiment that hay fever 
patients who choose to live permanently in hotel quarters above the 
eighteenth floor during the hay fever season, avoid the attacks. Un- 
fortunately for the maiori'ty of sufferers the above advice is for one 
reason or other prohibitive, and, for these, attempts should be made to 



NASAL NEUROSES. 649 

abort, ameliorate or entirely relieve the distressing affection. During 
-the quiescent period, it is of paramount importance to correct any 
intranasal disease or deformity which may incite the attack. Septal 
irregularities, hypertrophies of the soft tissue, polypi or accessory 
sinus disease must, receive appropriate surgical treatment. These sur- 
gical measures tend to obtund the hyperesthetic intranasal areas and 
help in abating the customary attack. When treatment is instituted 
during the attack of hay fever the intumescence can be greatly reduced 
by the following spray : — 
I£ Camphorse, 

Eucalyptol aa gr. j. 

Menthol gr. v. 

Albolene or benzoinol 3j. 

In the more obstinate cases it may be necessary to use cocaine or 
alypin in a normal salt solution from 4 per cent, to 10 per cent, com- 
bined with adrenalin chlorid in 1 : 10,000 to 1 : 2000 dilution. When 
cocaine is selected it should be used by the surgeon at proper intervals, 
and should not be left in the hands of the patient on account of the 
danger of habit formation. In certain individuals who are suffering 
from hay fever, applications of adrenalin solution to the nasal mucosa 
induce violent sneezing and otherwise aggravate the disease. Insuffla- 
tion of drugs in powder form is condemned ; the drug particles act 
as irritant foreign bodies on the nasal mucosa, and increase rather 
than relieve the distress. Dunbar's serotoxin made from the pollen of 
various grasses and known as "pollantin" was tried by the author in 
many cases, applied locally to the nasal mucosa, but has proven un- 
satisfactory. Since hay-fever patients have a more or less neurotic 
taint, tonics must always be included in the general treatment. The 
author prefers a combination of iron, quinine, arsenic and strychnine, 
which may be dispensed either as an elixir or in pill or tablet form 
and in doses suitable to the case. 

The attacks of hay asthma, occurring in nearly 50 per cent, of the 
cases of hyperesthetic rhinitis, must be treated on the same principle 
as the asthma occurring in other subjects (see Chapter XXXII), and 
need no special treatment at the hands of the rhinologist other than 
what has been outlined above. 

ASTHMA. 
Asthma is described in Chapter XXXII, on General Diseases. 

NASAL HYDRORRHEA (IDIOPATHIC RHINORRHEA). 

The term is employed to define a rare nasal phenomenon, the 
chief characteristic of which is a copious discharge of watery or 
slightly viscid, opalescent thud which contains mucin. The fluid is 
usually intermittent and absent during the night. According to St. 
Clair Thompson, "the addition of cither alcohol or acetic acid throws 
down a stringy precipitate like mucin. On boiling the precipitate with 
dilute sulphuric acid, a reducing sugar-like material is formed; this is 
also characteristic of mucin. The fluid contains a small amount of 
proteid, coagulable by heal ; it docs nol reduce Fehling's solution. 



650 NOSE AND NASAL ACCESSORY SINUSES. 

Proteoses and peptones are absent. The alcohol extract of the fluid 
contains no reducing substance. The presence of mucin and the ab- 
sence of the reducing substance are quite sufficient to distinguish this 
fluid from normal cerebrospinal fluid." 

Etiology. — The exact nature of this affection is not well known, 
but it is probable that several conditions, mostly neuroses, are causa- 
tive factors. 

Symptoms. — There are no characteristic symptoms save the 
.periodical flow of watery or viscid fluid from one or both nostrils, 
which reacts to the tests described in the previous paragraphs. Hand- 
kerchiefs soaked with the fluid become stiff upon drying. 

The attacks are commonly accompanied by malaise, sneezing, and 
irritation of the skin about the nostrils. 

Treatment. — There is no specific treatment. As a rule the dis- 
ease is self-limited. 

CEREBROSPINAL RHINORRHEA. 

We are indebted to §t. Clair Thompson (1899) for his analysis 
concerning the diagnostic character of the rare affection known as 
cerebrospinal rhinorrhea, or the' escape of arachnoid fluid from the 
nose. He (Thompson) favors the theory that the phenomenon results 
from intracranial pressure. Out of 21 recorded cases cerebral symp- 
toms were noted in 17 and retinal changes in 8. The flow usually is 
unilateral and exudes through the cribriform plate. The methods of 
testing the fluid in suspected cases, as outlined by Thompson, are : — 

1. The fluid is perfectly transparent like water, and contains no 
sediment. 2. It is faintly alkaline in reaction, and either tasteless or 
slightly salt. 3. The specific gravity is between 1005 and 1010. 4. It is 
not viscid, and gives no precipitate (mucin) on adding acetic acid. 5. 
On boiling there is not more than a trace of coagulum of serum 
globulin and serum albumin. 6. Cold nitric acid gives a precipitate 
which disappears on heating, and separates again on cooling. 7. Sat- 
uration with magnesium sulphate should give a precipitate. Saturation 
with sodium chlorid should also produce a precipitate. Ammonium 
sulphate should be tried if the above salts fail. 8. The liquid should 
give a pink or rosebud color with a trace of copper sulphate and excess 
of caustic potash. 9. When boiled with Fehling's solution there should 
be a reduction of the copper (due to pyrocatechin or some similar 
body). 10. The reducing substance may be obtained by evaporating 
to dryness an alcoholic extract of the fluid. It is then found in the 
form of needle-like crystals. 11. The aqueous solution of this residue 
does not ferment with yeast. There is no definite treatment known. 

EPILEPSY OF NASAL ORIGIN. 

Cases of petit mal and of epilepsy of supposedly nasal or post- 
nasal origin are reported in rhinological literature from time to time. 
In some cases the attacks date from some intranasal operative pro- 
cedure, and others have been associated with various intranasal 
diseases. The author has reported one case of petit mal (see Chapter 
XLII) in a child, which has subsided since the removal of a large, 
edematous polypus from the inferior turbinal. 



CHAPTER XLII. 
NEOPLASMS OF THE NOSE. 

Neoplasms of the nasal passages, barring myxomata, are rare, 
but the usual varieties, both benign and malignant, occur in the 
following forms : — 

Benign Neoplasms. — Myxomata, papillomata, fibromata, angio- 
mata, enchondromata, osteomata. 

Malignant Neoplasms. — Sarcomata, carcinomata. 

BENIGN NEOPLASMS. 
MYXOMATA OR NASAL POLYPI. 

Myxomata or edematous nasal polypi are the most common 
of all intranasal neoplasms. According to Woakes, the edematous 
mucosa is but a symptom of an underlying disease of the bone. 
Lack describes it as a "localized edematous infiltration of the nasal 
mucous membranes the result of osteitis of the underlying bone." 
Parker defines a nasal polypus as a "localized inflammatory edema 
of the mucoperiosteum of the ethmoid region inseparably asso- 
ciated with past or present disease of the bone" and questions the 
propriety of classifying them as new growths. They are oval, 
smooth, pedunculated or sessile gelatinous-appearing masses of 
varying size and contour. They are grayish or pink in color, and 
usually spring from the middle turbinal, the ethmoid, or more 
rarely protrude from the infundibulum, the sphenoidal ostium or 
the ostium maxillare. In rare instances they are attached to the 
inferior turbinal or the nasal septum. As a rule, nasal polypi arc 
multiple. They may entirely fill the nasal cavity and even project 
into the postnasal space, where they are prone to reach enormous 
size (Fig. 355) ; occasionally thev cause external deformity by 
spreading the nasal structures. The visible polypus often is but 
a portion of a general polypoid degenerative process, which has 
invaded the mucosa of one or more of the nasal accessory sinuses. 
It is now known that polypi which project through the nasoantral 
orifice have their primary seat in the mucosa of the maxillary 
antrum. The recent investigations of Killian bear directly upon 
the relation of this form of polypi to antral disease. The term 
"nasoantral polypi" has been suggested for tin's type. Furthermore, 
upon careful inquiry, a history of previous attacks of purulent sinu- 
sitis is obtainable. The symptoms of frontal headache and eth- 
moidal pain tend to verify this view. There are exceptions to this 
rule in which the pedicle of the polypus is attached to the inferior 
turbinal or septum. 

Xasal polypi are rare under the age of puberty. In children 
they are usually located upon the inferior turbinal and are prone to 
recur. The author has reported the following case: — 

(651) 



652 NOSE AND NASAL ACCESSORY SINUSES. 

W. A., aged 8, an undersized boy with a specific family history, had com- 
plained for some months of difficulty in nasal breathing, and his parents, deem- 
ing the cause to be adenoids and hypertrophied tonsils, sought relief. Upon 
examination it was found that he had a large tumor occupying the postnasal 
space, with an attachment at about the junction of the middle and posterior 
portions of the left inferior turbinal. Under ether anesthesia this growth was 
removed in the following manner : — 

After several ineffectual attempts to surround the mass with a large wire 
loop, introduced through the nostril, a simpler procedure was employed, namely, 
with a pair of strong clipping forceps the pedicle of the growth was grasped 
and severed. The growth then fell backward into the nasopharynx, and was 
withdrawn through the mouth. The child was not well nourished, had Hutch- 
inson teeth, and had been subject to frequent attacks of petit mal. The growth 
was examined by Dr. Jonathan Wright, who found it tt> be an ordinary edem- 
atous polypus. Dr. Wright further observed that, so far as he knew, it was the 
youngest case on record, and that recurrence was more frequent in the very 
young. After one and one-half years the growth had reappeared, and was fully 
as large as the former one. It was removed by the same method as that pre- 
viously employed, with the exception that a considerable section of the inferior 
turbinate bone was cut away, hoping thereby to eradicate the source of the 
tumor and prevent its recurrence. The second removal was followed by a 
marked diminution in the frequency of his attacks of petit mal. After a lapse 
of two years there was no recurrence of the growth, his attacks of petit mal had 
disappeared, and his general health and appearance had improved. 

Pathology. — Pathologically, nasal polypi are usually fibro- 
myxomata rather than myxomata, inasmuch as they are composed 
of edematous mucous membrane, intermingled with inflammatory 
products. The surface or sac is covered with epithelium and is 
supplied with blood-vessels and scattered nerve filaments. 

Symptoms. — The symptoms of nasal polypi are chiefly refer- 
able to the nasal obstruction which they produce. Inasmuch as 
these neoplasms are commonly associated with inflammatory affec- 
tions of the nasal accessory sinuses, the symptoms are necessarily 
more or less complicated. Pedunculated growths, which hang more 
or less loosely in the nasal cavity and hence are movable, produce 
a sensation of a foreign body in the nose. As a rule they give rise 
to a watery discharge, especially in damp weather or during the 
course of attacks of simple acute rhinitis. The voice is materially 
affected, its timbre diminished, and when the obstruction is exten- 
sive it has a pronounced nasal twang. A variety of distressing 
reflex symptoms are provoked by polypi of large dimensions, 
especially when they are bilateral, the chief of which are mouth 
breathing, rhinorrhea, cough, asthma, anosmia, aprosexia and 
sneezing. 

Diagnosis. — The diagnosis is never difficult, and is based upon 
the appearance within the nasal chambers of the gelatinous-like 
masses, which may be single, multiple, pedunculated or sessile. They 
vary in size from a millet seed to those which fill the nasal chamber 
and a large portion of the postnasal space. 

Treatment. — The form of operative procedure required for the 
eradication of nasal polypi depends upon the location of the growth 
or growths, the activity of the inflammatory process, and whether 
these growths are a part of an associated osteitis or purulent sinu- 
sitis. A single, pedunculated polypus, unaccompanied by pus dis- 



- NEOPLASMS OF THE NOSE. 653 

charge, thus indicating the cessation or absence of disease of the 
underlying bone, may be removed without the necessity of inter- 
fering with the bone to which it is attached. In case one or more 
edematous polypi are attached to the surface of the middle turbinal, 
or are found to project from the ethmoidal cells or one or more of 
the nasal accessory sinuses, a more radical procedure becomes neces- 
sary, which must include a complete removal of the associated 
disease of the bone and its coverings. 

In order to clearly define the surgical significance of the more 
common locations of nasal polypi, it may be stated that (a) polypi 
having their origin upon the free surface of the middle turbinal 
indicate that at most the underlying disease does not extend beyond 
the anterior ethmoidal cells. Polypi which project from the spaces 
above the middle turbinal usually have their site of origin in the 
posterior ethmoidal cells, (b) Polypi which occupy a position 
between the inferior and outer surface of the middle turbinal and 
the outer nasal wall, originating in and about the region of the 
hiatus semilunaris, represent a type which usually springs from the 
frontal sinus, maxillary antrum, or anterior ethmoidal cells. 

Finally, the rare locations are upon the inferior turbinal and 
nasal septum. 

Surgical Technique. Preparation of the Patient. — The intranasal 
surfaces should be prepared for operation in a manner similar to that 
described for operations upon the middle and inferior turbinals (see 
Chapter XXXVI), except that the employment of adrenalin should 
be avoided on account of the remarkable shrinking of the growths 
which is caused by this drug. The employment of adrenalin is 
permissible during the later steps of the operation to control hemor- 
rhage. Cocainization of the areas to be approached should be as 
complete as possible. 

Operative procedures must vary in accordance with the site of 
the tumor, its extent and the nature of the underlying disease 
which latter is present in a large proportion of all cases. 

Simple Operation. — This term is meant to define the operation 
which suffices for the removal of potypi alone, whether located in 
the nasal cavities or extending into the postnasal space. The wire 
snare (Fig. 351) is best adapted for the removal of polypi which 
are located in the nasal cavities. Numerous snares have been 
devised for this purpose since Jarvis first introduced this method 
of operation. The rhinologist should select the snare which is best 
suited to his mode of technic. 

The snare loop should be introduced into the nasal cavity 
under bright illumination and so manipulated that its loop is 
carried around the tumor and made to engage the entire mass. An 
assistant may be instructed to hold the nasal speculum. When 
large tumors are encountered and the loop has been carried par- 
tially over the surface of the mass, that portion of the tumor which 
has already passed through the loop may be grasped with forceps, 
pulled forward and held firmly until the wire is thoroughly adjusted 



654 NOSE AND NASAL ACCESSORY SINUSES. 

around the pedicle. Thereafter the pedicle should be slowly 
divided by tightening the wire. 

When it is known that the polypus projects through the orifice 
of an accessory sinus or from an ethmoidal cell, the snare may be 
adjusted around any portion of the growth so long as a firm hold 
of the tumor is secured. After tightening the wire upon the growth, 
traction should be made and the tumor mass pulled out. It often 
transpires that in so doing the mass finally pulled away from the 
cavities is far in excess of the small portion which has primarily 
been engaged in the loop (Fig. 427). 

As a rule the operation is followed by slight hemorrhage, which 
quickly subsides. In case of multiple polypi the procedure should 
be repeated until all are removed. 

Postnasal polypi are usually of large size and long standing. 
They are pedunculated, and as a rule spring from the mucosa of 




Fig. 427. — The illustration shows the benefit to be gained by traction 
rather than by severing the polypoid mass. 

the middle turbinal, but the site of origin may be upon the septum 
or the inferior turbinal. 

In another method which has its advocates a large loop of wire 
is projected through the nostril into the nasopharynx. The loop 
is then manipulated by the index finger of the operator inserted 
into the postnasal space until it has been made to surround the 
growth. Still holding the wire loop in position, an assistant is 
instructed to insert the distal ends of the wire through a snare 
cannula and to tighten the wire until the pedicle has been severed. 
The author strongly recommends the method heretofore described, 
whereby the pedicle of the polypus is severed and the tumor with- 
drawn through the mouth. Fig. 428 illustrates a large gelatinous 
polypus which was removed from the nasopharynx by severing its 
attachment (pedicle) from the middle turbinal. 

The Removal of the Polypi when Associated with Underlying Bone 
Disease or Polypoid Degeneration of the Mucosa of the Accessory 
Cavities. — These conditions have received due attention under the 
appropriate headings in the preceding chapters. 

After-treatment. — When considerable hemorrhage follows the 
operation, it is usually easily controlled by slight pressure with a 



NEOPLASMS OF THE NOSE. 655 

section of sterile gauze which has been immersed in a solution of 
adrenalin 1 : 5000. Otherwise it is rarely necessary to leave any 
dressings in the nasal cavities. The subsequent treatment consists 
of cleansing alkaline sprays, night and morning, for eight or ten 
days. Before discharging the patient the nasopharynx should be 
carefully inspected by the surgeon, in order to determine that no 
recurrence has taken place. 

PAPILLOMATA. 

True papillomata rarely are found in the nasal cavities. They 
occasionally develop in the vestibule or the free surface of the inferior 
turbinal and the anterior and lower portion of the septum. On 
account of their small size they produce few symptoms. 




Fig. 428. — Large mucous polypus, exact size, removed from the nasopharynx 
by severing its attachment (pedicle) from the middle turbinal. 

Treatment. — A pedunculated papilloma, wherever located, 
should be excised by means of snare or scissors, and its base cauterized 
with fused chromic acid, nitric acid, or the galvanocautery. Occasion- 
ally they are sessile and extremely small, in which case they are con- 
veniently destroyed by means of galvanocauterization. 

FIBROMATA. 

Intranasal fibromata are of exceedingly rare occurrence. Usually 
they spring from the septum, turbinate bodies, or the floor of the 
nares, but cases have been reported of fibromata arising from the 
periosteum in other portions of the nasal chambers, especially the lateral 
nasal wall. They occur as sessile growths or singly, and are made up 
of dense fibrous tissue which contains large blood-vessels. 

Symptoms. — "Flic chief symptom is nasal obstruction, which is 
usually attended with mucopurulent discharge. As the growth in- 
creases there is considerable pain, the discharge becomes mucopurulent, 
and external deformity of the nose may result. In extreme cases nasal 
respiration becomes impossible, and anosmia and headache appear. 
Ulcerations are common, and death may finally result from exhaustion, 
or on account of t lie extension of the growth into neighboring vital 



656 NOSE AND NASAL ACCESSORY SINUSES. 

structures. The latter symptoms are avoided by timely surgical 
interference. 

Prognosis. — The prognosis is usually favorable in cases which 
are subjected to surgical interference, although recurrences are 
common. 

Treatment. — Complete surgical removal constitutes the only 
feasible treatment for fibromata of the nasal passages. The method 
employed depends upon the character, location and size of the growth. 
The cold-wire snare is suitable for the removal of growths of small 
size. It is important that both the snare and the wire loop should be of 
sufficient strength to cut through the dense fibrous tissue. Advanced 
cases where the growth has become too extensive to be removed by 
means of the cold-wire snare should be removed piece by piece, or 
by some form of external operation. Of the external operations that 
known as Langenbeck's is the one in common use. The removal 
of fibromata is invariably attended by free hemorrhage, and in every 
instance the base of the growth should be thoroughly seared over 
with the galvanocautery. In the after-treatment the usual cleansing 
remedies should be employed. 

ANGIOMATA. 

Angiomata of the nasal cavities occur with extreme rarity. They 
are characterized by the appearance upon the nasal septum of vascular 
excrescences, which are usually sessile in character, of variable size, 
but rarely larger than a hickory nut. They are extremely vascular 
and hemorrhagic. They are rarely painful, and the chief symptoms 
are nasal obstruction and hemorrhage. 

Treatment. — Two methods of treatment are in vogue: 1. 
Strangulation. 2. Enucleation. 

Strangulation is produced either by means of a cold-wire snare or 
a galvanocautery snare. In the former the growth is enucleated by 
slowly tightening the wire loop. Sufficient time should be employed to 
strangulate rather than to suddenly sever the blood-vessels surrounding 
the growth. When the galvanocautery wire loop is employed, the 
same result is produced by coagulation from the heat. 

Enucleation is accomplished by extending a circular incision 
through the mucochondrium. entirely around the growth. The incision 
should be made at a slight distance from the base of the growth. The 
entire mass, including the perichondrium, is then peeled away from the 
septum. During the time required for the subsequent healing the nasal 
passages should be kept clean by the use of alkaline sprays. 

ENCHONDROMATA. 

Cartilaginous tumors developing within the nasal cavities, barring 
septal spurs, are extremely rare. They spring from the septal cartilage 
and, when of large dimensions, produce nasal obstruction and pres- 
sure symptoms. 

Treatment. — Surgical removal constitutes the only feasible 
treatment. Tumors of moderate size may be removed by intranasal 



NEOPLASMS OF THE NOSE. 657 

methods, but in rare instances external operation becomes imperative 
in order to enable the operator to expose and excavate the tumor. 

OSTEOMATA. 

Osteoma is a rare form of benign growth which usually develops 
in an accessory sinus and gradually projects into the nasal cavity. The 
frontal sinus is probably the most frequent seat of the disease, although 
cases have been reported of osteoma developing in the ethmoidal cells 
and the antrum of Highmore. Boenhaupt tabulated 23 cases of 
osteoma which developed in the frontal sinus. The growths may 
invade the cerebral, orbital or nasal cavities, and even cause marked 
external facial deformity. Osteomata are usually more or less 
pedunculated, of pinkish color, and are made up of dense, cancellous, 
bony tissue. In the spongy type there is usually a dense, bony sur- 
rounding capsule. 

Symptoms. — Nasal obstruction is usually an early and promi- 
nent symptom. Pressure pains of a neuralgic character become 
prominent in proportion as the growth produces pressure upon the sur- 
rounding tissues. Finally secondary symptoms of deformity appear, 
chief of which are protrusion of the eyeball and widening of the nasal 
bones. 

Treatment. — External operation offers the only hope of com- 
plete eradication of the disease. In rare instances wherein the growth 
is confined to the anterior nares it is possible to remove the growth 
intranasally, by means of chisel or drill. 

MALIGNANT NEOPLASMS. 
SARCOMATA. 

Of the malignant neoplasms of the nose, sarcomata are the more 
common. They may develop in infancy, childhood or adult life. 
Rarely are they found in old age. The growths may spring from the 
turbinals, nasal septum, or the accessory sinuses. Of the latter the 
antrum is usually the seat of the disease. 

Symptoms. — Mentioned in order, the symptoms are nasal 
obstruction and pain of neuralgic type, which usually manifests a 
tendency to radiate to the areas which surround the tumor. Recurrent 
epistaxis becomes a prominent symptom as soon as the surfaces of the 
tumor commence to ulcerate. A more or less continued purulent dis- 
cbarge accompanies the later stages of the disease. Finally, secondary 
symptoms appear, the chief of which are external deformities and 
intracranial involvement. 

Diagnosis'. — The chief diagnostic points are : nasal obstruction, 
the appearance in the nasal cavity of a large, broad-based fungus-like 
tumor of hemorrhagic type, moderate pain, and in advanced cases 
external deformities and symptoms of intracranial pressure. Finally, 
a positive diagnosis must depend upon a microscopic examination of a 
section of the growth. 

Prognosis. — The prognosis is invariably grave, but less so than 
in carcinoma. Sarcomata in young children sometimes disappear 



658 XOSE AXD XASAL ACCESSORY SINUSES. 

spontaneously. Early and radical removal of the growths constitutes 
the only known method for the eradication of the disease. So far the 
results of serum therapy (hereinafter mentioned) have remained 
unfavorable. In the majority of cases the disease terminates fatally. 

Treatment. — As above mentioned, the treatment of this disease 
is essentially surgical. In rare instances only is it possible to success- 
fully remove a sarcoma from the nose by intranasal operation. A 
small tumor springing from the anterior nares may be successfully 
extirpated intranasally. The removal of growths of larger size, 
especially when springing from the deeper portions of the nasal 
cavities or the accessory sinuses, requires extensive external 
procedures. 

The removal of incipient small-sized sarcomata from the nasal 
septum or anterior portion of the lateral walls by the intranasal 
operation is prone to be followed by local recurrence. A recur- 
rence of the growth should immediately be attacked with the dull 
curet or galvanocautery. While permanent recovery is not the 
rule, a small percentage of cases of sarcoma are curable. 

Sarcomatous growths which have arisen from the deeper por- 
tions of the nares, or from the nasal accessory sinuses, are amenable 
to treatment only by external surgical operation. The Rouge 
operation heads the list of the external operations, and is favored 
because it produces no unsightly scarring of the face. It is per- 
formed by extending an incision along the line of junction of the 
mucous membrane of the under surface of the upper lip with the 
superior maxillary bone. The entire lip, together with the perios- 
teum, is thus lifted upward with retractors. A second incision into 
the nasal cavities is then made, through the primary wound beneath 
the upper lip. Forcible retraction upward, together with a further 
separation of the periosteum from beneath, enables the operator to 
obtain a clear view of the nasal cavities, and to remove the entire 
growth. A considerable area of the surrounding healthy tissue 
should also be cut away, in order if possible both to eradicate and 
exterminate the neoplasm. The prevalence and severity of the 
hemorrhage during all operations for the removal of sarcomata 
requires the tamponing of the postnasal space as a preliminary 
measure. 

Of the remaining external operations Ollier's. Langenbeck's 
and Dieffenbach's are worthy of mention. Ollier's operation con- 
sists in extending an incision to the bone along the line of attach- 
ment of the nose to the face, from the ala of one side upward, 
thence across the nasal bridge and downward to the ala of the 
opposite side (Fig. 429). The nasal bones are then divided from 
their attachment with a chisel or light saw, and forcibly turned 
downward, leaving a clear view of the deeper nasal regions. The 
growth is then removed as above described, after which the dis- 
placed bones and soft tissues are replaced and the external wound 
united with sutures. The bones should be protected from injury 
until readjusted by means of strips of adhesive plaster, or of suitable 
splints. 



NEOPLASMS OF THE NOSE. 659 

Treatment by the X-ray and by Serum Therapy. — The X-ray 
treatment of both carcinomata and sarcomata, when arising from 
the deeper portions of the nasal cavities, has proved most disap- 
pointing. A few favorable reports have appeared in literature, but 
authentic reports from authors of wide experience are almost 
invariably unfavorable. Furthermore there is abundant evidence 
that harm may be done by this measure by those who are inex- 
perienced regarding its properties. 

Serum Therapy. — Serum therapy has been advocated by Coley in 
inoperable cases, using for this purpose the mixed toxins of the 
Bacillus prodigiosus and Streptococcus erysipelatosus. His reports 
would indicate that in a limited proportion of cases of inoperable 
cancer the serum has been effective. 

The enzyme treatment for cancer (trypsin and amylopsin) has 
been tested scientifically by Bainbridge, whose report 1 concludes 



^TO 




Fig. 429. — Ollier's incision for the purpose of obtaining a wide 
opening of the nasal cavities. 

with this statement : "That the enzyme treatment as administered 
in cases reported and according to the suggestions of Dr. Beard 
plus extra details of regime does not check the cancerous processes, 
nor does it prevent metastasis." 

Treatment of Inoperable Cases. — In inoperable cases it is 
important to maintain nasal respiration as long as possible by the 
removal of large sections of the growth and by cauterization. The 
secretions should be washed out with alkaline sprays, and the pain 
should be relieved by local applications. An application of ortho- 
form three or four times daily will usually afford relief until the 
pain becomes unendurable on account of the encroachment of the 
tumor upon the more vital structures, when the hypodermic use of 
morphine should be resorted to. Ligation of the common carotid upon 
the affected side produces a marked remission in the progress of the 
disease, temporary relief from hemorrhage and many of the distressing 
symptoms. Unfortunately said relief i^ only temporary (two or three 
months). 



1 The Enzyme Treatment for Cancer. Final Report. Medical Record, 
July 17 and August 7, 1909. 



660 NOSE AXD XASAL ACCESSORY SINUSES. 

CARCINOMATA. 

Primary carcinoma of the nose and the nasal accessory sinuses 
is of rare occurrence. It is less common than sarcoma, and, umike 
sarcoma, it usually occurs after the fortieth year. In this location 
the alveolar carcinoma and the epithelioma are found. The author 
has reported a case of primary epithelioma of the maxillary sinus 
which extended through a tooth-socket into the mouth. 

Diagnosis. — The important diagnostic phenomena are: 1, grad- 
ually increasing unilateral nasal stenosis ; 2, mucopurulent discharge ; 
3, persistent pain; 4, the appearance of an indurated ulcer; 5, epi- 
staxis; 6, odor (due to necrosis of soft and bony tissues); 7, ex- 
ternal deformity and impairment of vision as a result of extension of 
the disease into the ethmoid cells and orbit ; 8, cachexia ; 9, microscopic 
examination of a section removed from the growth. 

Prognosis. — The prognosis is unfavorable, and recoveries are 
rare. 

Treatment. — An early diagnosis, followed by complete surgical 
eradication of the growth, offers the only hope of cure for a car- 
cinomatous neoplasm in the nose. In advanced cases operative 
interference is contraindicated. The surgical, postoperative and 
palliative treatment is similar to that of sarcoma, heretofore 
described. 



SECTION II. 

The Pharynx and Fauces. 



CHAPTER XLIII. 
DISEASES OF THE NASOPHARYNX. 



SURGICAL ANATOMY. 

The nasopharynx is that portion of the upper respiratory tract 
which occupies the space bounded above and anteriorly by the 
choanae (Fig. 430) and posterior surface of the velum, and below 
by a plane on a level with the nasal floor. It is a somewhat quad- 
rilateral shaped cavity (Fig. 431), the roof of which is chiefly 
formed by the basilar process of the occipital and the posterior 
portion of the sphenoid bones. The spinal column supports its 
posterior wall. Where the posterior wall of the nasopharynx 
becomes continuous with the superior there is a rounded curve 
which is designated as the fornix pharyngi. 

The fornix is the seat of the pharyngeal or Luschka's tonsil, a 
lymphoid glandular structure which exists in this region in the 
shape of a yellowish-red, soft, irregular swelling. 

The lateral wall contains the pharyngeal opening of the Eu- 
stachian tube, which lies about 1 cm. behind the posterior border of 
the inferior turbinal bone. The tubal prominence is somewhat 
bulbous and triangular in shape, the opening of which is either 
round or slit-like (Fig. 431). Surrounding the tubal orifice is the 
torus tubulus, from the posterior part of which the salpingopharyn- 
geal fold passes downward, carrying with it a portion of the palato- 
pharyngeal muscles which arise from the tubal cartilage. 

When the velum palati (Fig. 431) is relaxed the nasopharynx 
communicates freely with the oropharynx, and the nasopharyn- 
geal space opens widely, laterally as well as forward and back- 
ward, into the oropharyngeal cavity. 

The capacity of the space, according to Luschka, does not 
amount to more than 14 c.c, its width being subject to considerable 
individual variations, depending upon the size of the body in 
general. With the exception of the upper and posterior walls the 
surfaces are mucous and undergo considerable variations of shape 
during respiration, speaking, swallowing, etc. The superior wall is 
almost devoid of muscles, the mucosa being in direct contact with 
the tissues of the basilar fibrocartilage. 

The lateral wall of the nasopharynx recedes so as to form a 
deep niche, which is called the pharyngeal recess of Rosenmiiller or 
Rosenmiiller's fossa. Merkel has "made use of the term infun- 

(661) 



662 



THE PHARYNX AND FAUCES. 



dibuliform recess for this fossa. The width of this recess is largely 
dependent upon the development of the adenoid layer between the 
pharyngeal tonsil and the tubal orifice. The recess is attached 
above to the lower surface of the temporal bone and is bounded 
behind by the solid connective tissue which covers the vessels and 
nerves of the neck. The arterial supply of the tissues of the naso- 
pharynx comes from the external carotid. The veins empty into 
the external jugular and the common and posterior facial veins. 
The lymph-vessels are connected with the deep glands of the face. 
The nerve supply emanates: 1, from the trigeminus; 2, from the 
pharyngeal branch of the glossopharyngeal ; 3, from several 
branches and the vagus and spinal accessory, and, 4, from the sym- 




Fisr. 430. — The choanae. 



pathetic. The fibres of the last three unite in a lateral plexus, from 
which the terminal fibres take their origin. 

The mucous membrane of the nasopharynx normally is the 
seat of lymphoid (adenoid) tissue. These glandular structures are 
prone to undergo pathological changes, the chief of which is true 
hyperplasia of the lymphoid tissue. 

A blind pouch sometimes found lying behind the adenoid sub- 
stance, the pointed extremity of which becomes inserted into the 
outer fibres covering the occipital bone, has been termed the 
pharyngeal (Thornwaldt's) bursa. This bursa is rare and opinions 
are divided as to its significance. Killian regards it as a structure 
independent of the pharyngeal tonsil and originating through active 
proliferation of the mucosa. Histologically the pharyngeal tonsil 
consists of adenoid tissue imbedded into the tunica propria of the 
mucosa, and undergoing gradual retrogression after puberty, so 
that it is rarely met with after the thirtieth year. The areas above 



THE NASOPHARYNX. 



663 




Fig. 431.— Lateral view of the anatomical conformation of the 
nose, nasopharynx, pharynx, and larynx. (From 
Dearer, with permission.) 



superior meatus, 
superior turbinate body, 
middle turbinate, 
inferior turbinate. 
inferior meatus, 
tongue. 

posterior pillar of fauces, 
geniohyoglossus muscle. 
geniohyoid muscle, 
hyoid bone, 
mylohyoid muscle, 
thyrohyoid membrane, 
ventricle of larynx, 
thyroid cartilage, 
diaphragma sella'. 
cavum scllae. 
sphenoidal sinus. 
middle meatus. 



rhinopharynx. 

Eustachian orifice. 

hard palate. 

soft palate. 

uvula. 

anterior pillar of fauces. 

tonsillar fossa. 
, oropharynx. 
, epiglottis. 

aryi piglol I Ic fold. 
. laryngopharynx. 
Buprarimal portion of larynx. 

v ill ih'ii l.i r bl 

, vocal band. 

ol larynx 
cricoid cartilage. 

tracheal ring. 



664 THE PHARYXX AND FAUCES. 

described are examined either by ordinary rhinoscopy or by means 
of the Hays pharyngoscope (Fig. 494). 

ACUTE NASOPHARYNGITIS. 

The mucosa lining the nasopharynx often becomes the seat of 
acute inflammation, and, while the inflammatory process usually 
occurs in conjunction with rhinitis and pharyngitis, cases are seen 
in which the nasopharynx is primarily the seat of an inflammatory 
process to which the symptoms are clearly referable. It occurs 
during seasons of dampness and sudden changes, and is invariably 
aggravated by the excessive use of tobacco and stimulants. 

Etiology. — So far as known, exposure to cold, in a person other- 
wise predisposed by fatigue, ill health or some form of constitu- 
tional dyscrasia, is the prime etiological factor. In young children 
with diseased adenoid tissue it is extremely common. 

Symptomatology. — The attack is usually sudden, often being 
first felt upon arising from sleep. There is a disagreeable sensation 
of irritation and dryness, with considerable pain, located in the 
upper part of the throat. A slight rise of temperature, with some 
increase in the pulse rate and more or less prostration, is usual. It 
is not unlikely that in certain cases the nasopharyngeal inflamma- 
tion results from some disturbance of the digestive tract. After a 
day or two a mucopurulent discharge appears, which is sufficiently 
thick and tenacious to require considerable effort to dislodge. 
Persistent hawking is one of the marked symptoms of the second 
stage of the disease, and its indulgence often produces gagging and 
vomiting. The voice is usually impaired and metallic in quality. 
As a rule the oropharynx partakes of the inflammatory process, but 
the larynx and bronchial tubes do not become involved. Inflamma- 
tion and swelling of the Eustachian tubes is a common symptom 
and it is prone to induce obstruction of the tube, which, in turn, 
causes acute catarrhal otitis media (see Chapter XVI). 

Treatment. — As a rule the treatment employed should be the 
same as for acute rhinitis (see Chapter XXXIII). 

SIMPLE CHRONIC NASOPHARYNGITIS. 

Synonyms. — Nasopharyngeal catarrh ; chronic postnasal ca- 
tarrh; hypertrophic nasopharyngitis. 

Chronic nasopharyngitis is an inflammatory process involving 
the mucosa of the nasopharynx and characterized by a secretion 
of tenacious mucus, sometimes mucopurulent, from the glandular 
structures. 

Etiology. — Chronic nasopharyngitis rarely occurs independ- 
ently of chronic hyperplastic rhinitis ; hence the latter is the chief 
etiological factor (see Chapter XXXIV). Occupation, exposure 
and the dust which accompanies various forms of employment, in 
tobacco factories, clothing institutions, etc., also the various 
mechanical occupations, are contributing causes; meanwhile badly 



THE NASOPHARYNX. 665 

nourished individuals who live under unhygienic surroundings are 
peculiarly liable to this disease. 

Pathology. — In general the pathological changes in the mucosa 
are similar to those which occur in chronic rhinitis (see Chapter 
XXXIV). In addition there are marked changes in the lymphatic 
tissues, especially in Luschka's tonsil, which may become much 
enlarged. 

Symptomatology. — The symptoms are chiefly referable to the 
annoyance associated with the constant sensation of dryness and 
the irritation produced by the retention of tenacious mucus upon 
the walls of the pharynx, the retained secretion often becoming 
inspissated, thus adding materially to the discomfort. The secre- 
tion should be differentiated from that which flows into this region 
from empyema of the posterior ethmoidal cells and the sphenoidal 
sinuses. The patients "hem" and "hawk" almost incessantly, much 
to their own annoyance and to that of their acquaintances. Upon 
examination the mucous membrane is inflamed and thickened. The 
secretions accumulate upon the posterior wall or flow down into the 
pharynx. With each exacerbation the Eustachian tubes are ex- 



^£ ffi— a 




Fig. 432. — The author's flexible cotton carrier. 



tremely liable to become involved in the inflammatory process and 
attacks of catarrhal otitis media result. Tubal obstruction, tinnitus 
and deafness may eventually result. The voice loses much of its 
timbre, and the prolonged efforts to release the retained secretion 
may result in relaxation of the soft palate and uvula. 

Treatment. — The general treatment of this affection is similar 
to that of chronic rhinitis (see Chapter XXXIV) and includes the 
prohibition of tobacco, alcohol and irritant condiments, the regula- 
tion of diet and digestion, and the adoption of proper measures of 
hygiene. Furthermore it is imperative that intranasal diseases and 
defects should be eliminated. 

Locally the first step is the careful and complete removal of all 
secretions. This is best accomplished by means of the postnasal 
syringe (Fig. 305), making use of the procedures and solutions 
recommended for atrophic rhinitis (see Chapter XXXIV). It is 
not difficult to train patients to wash out the nasopharynx by means 
of the ordinary nasal spray, directing that while spraying either 
nostril to throw the head backward and to breathe entirely through 
the wide-open mouth. By this procedure the velum is made to lit 
closely to the posterior wall, and the fluid collects in sufficient 
quantity to wash the mucous surfaces. The danger of middle-ear 
involvement is overcome by directing the patient to blow the nose 
without shutting off either nostril; in other words, to blow through 
both nostrils simultaneously, or to refrain from blowing until the 



666 THE PHARYNX AND FAUCES. 

fluid has largely passed backward into the mouth. It is sometimes 
necessary to use a curved applicator (Fig. 432), cotton-tipped, in 
order to remove retained masses of secretion. After cleansing, the 
mucous surfaces of the nasopharynx may be painted with mild 
astringents. Argyrol in 25 per cent, solution, Mandl's solution 
(see page 514), nitrate of silver, 20 to 40 grs. to the ounce, or boro- 
glycerid. 5 per cent., applied with a curved cotton-tipped applicator 
(Fig. 432), are useful. 

Adenoids when present should invariably be removed. Like- 
wise the pharyngeal bursa and adhesive bands whenever they are 
present. 

ATROPHIC NASOPHARYNGITIS. 

Synonym. — Nasopharyngitis sicca. 

Atrophic nasopharyngitis is always identical with atrophic rhinitis, 
with the same etiological factors and pathology. 

Symptomatology. — The chief symptom is a sensation of 
extreme dryness and the formation and retention of crusts, which 
usually cover the greater portion of the entire mucosa. The annoy- 
ance is so great with many patients that, in addition to the constant 
hawking and snuffing, they resort to the introduction of the finger 
into the postnasal space to get relief. Every two or three days 
large masses become dislodged, which often form almost a complete 
cast of the nasopharynx. Examination reveals the presence of 
these crust formations, with but little normal watery secretion. 
The atrophic process is prone to involve the middle ear. The dis- 
ease is extremely obstinate and requires the most painstaking and 
long-continued treatment. 

Treatment. — In addition to the treatment heretofore described 
for the associated atrophic rhinitis (see Chapter XXXIV), the naso- 
pharynx requires frequent and painstaking treatment, commonly 
covering a period of many months or even years. The aim of the 
treatment largely should be to remove the crust masses with suffi- 
cient frequency to relieve the individual of the uncomfortable 
sensations which they induce, and to restore as far as possible the 
normal state of the mucosa. The postnasal syringe (Fig. 305) will 
usually suffice to dislodge the secretions, but in the more obstinate 
cases the entire removal of the crusts can be accomplished only by 
means of a curved cotton carrier (Fig. 432), aided by the rhinoscopic 
mirror. It is quite possible to train patients to relax and otherwise 
control the pharynx so that the operator, by employing a small 
rhinoscopic mirror, is able to observe the various steps in the treat- 
ment. 

After thorough cleansing, the surfaces should be swabbed with 
ichthyol 25 per cent. The success of the treatment is largely dependent 
upon the frequency and thoroughness of the process of cleansing, and 
of the stimulating medicaments. It is often necessary to prolong the 
period of treatment from three to six months, and the fidelity and 
persistence of the patient should equal that of the surgeon. 



THE NASOPHARYNX. 



667 



ADENOIDS. 

Synonyms. — Hyperplasia of the lymphoid tissue in the naso- 
pharynx ; hypertrophy of Luschka's tonsil ; hypertrophy of the third 
tonsil. 

The memorable day in 1870 when Wilhelm Meyer published 
his classic treatise giving to the world the results of his original 
researches in the realm of the glandular structures of the naso- 
pharynx marked a distinct advance in our knowledge of the path- 
ology and treatment of these structures, and thereby he bestowed 
a lasting boon upon child life. 

The lymphatic tissues which bear the name ■ "adenoids" are a 
series of lymph-glands which are superficially located in the mucosa 




Fig. 433. — Sessile masses of adenoids in the vault of the pharynx. 

of the vault and posterior wall of the nasopharynx. They form the 
upper segment of the chain of superficial lymph-glands which extends 
from the pharyngeal or Luschka's tonsil to the lingual tonsil and 
known as Waldeyer's ring. 

The nasopharynx frequently is the seat of hyperplasia in which 
the normal lymphoid glandular structures become involved in this 
form of inflammatory process. It should be remembered that these 
lymph-glands in this locality are physiologically normal under 
healthy conditions, and require treatment only when they become 
the scat of hyperplastic enlargement (Fig. 448). 

Etiology. — This affection is essentially one of child life and is 
more commonly observed between the ages of three and twelve 
years. In a small percentage of infants the disease appears soon 
after birth and seriously interferes with respiration and nursing. 
The author has found it necessary to operate as early as the fourth 
month. Heredity is an important etiological factor both in races 
and in families. One rarelv fails to find a family history of adenoids 



668 THE PHARYNX AND FAUCES. 

in one or both parents, and it is commonly necessary to operate 
upon an entire family of children. It is difficult to otherwise 
explain why hypertrophy occurs in some children and not in others, 
and why the disease is no respecter of persons, whether rich or 
poor. Climate exerts a marked influence upon this affection. 
Dampness and sudden changes, by inducing inflammation of the 
upper air passages, tend secondarily to favor hyperplasia in the 
lymph-glands of the nasopharynx. Bad hygiene, especially the 
inhalation of vitiated air and impurities, such as irritating gases, is 
a predisposing cause. Purulent rhinitis in its various forms is a 
common exciting cause of adenoids. Furthermore, the exanthe- 
mata, grippe and all infectious fevers, by their tendency to induce 
intense inflammation and engorgement of the nasopharyngeal 
mucosa and consequent alteration in the secretions, often mark the 
beginning of permanent hyperplasia of the pharyngeal tonsil 
(adenoids). Hence, the causes of the above-named affections must 
be considered predisposing causes of adenoids. 

Glandular hypertrophy in the pharyngeal vault is usually asso- 
ciated with more or less hypertrophy of ihe faucial and lingual 
tonsils. 

Nasal obstruction increases the tendency to hyperplasia of the 
lymphoid tissue in the nasopharynx. While adenoid hyperplasia 
is most commonly met between the ages of five and fifteen and 
somewhat more rarely between fifteen and twenty, it occasionally 
remains to old age. The affection occurs about equally in both 
sexes. 

The growths occur in two chief forms — first, hyperplasia or 
uniform thickening of the pharyngeal tonsil, in which the mass 
appears as a globular or flattened tumor, and, second, diffuse hyper- 
plasia, wherein the growths are sessile and mulberry-shaped without 
the appearance of being a uniform tumor (Fig. 433). The first- 
named variety is more common, but both forms may exist simulta- 
neously. The consistency of these growths is extremely variable. 
They may be so friable as to be easily crushed by the finger, or so 
dense that considerable force is required to cut through the masses 
with sharp cutting forceps. They tend to become more dense in 
adult life. These differences probably result from the relative 
amount of connective tissue in the tumor masses. They are 
extremely vascular. In addition to the above-described etiological 
factors the existence of an underlying predisposition (lymphatic 
diathesis) is probable. 

Pathology. — Under normal conditions the mucosa of the 
posterosuperior nasopharyngeal wall contains superficial lymph- 
glands. According to McBride and Turner, they consist of a mesh- 
work of fibrous connective tissue, which supports the lymphoid 
cells, but on account of their superficial location they differ from 
the more deeply seated lymphatic glands by having an epithelial 
covering which is continuous with that of the surrounding mem- 
brane. The pathological changes which result in enlargement 
seem not to be those arising from excessive connective-tissue develop- 



THE NASOPHARYNX. 



669 



merit, but of excessive lymphoid development, although occasion- 
ally in the more dense varieties there is a true hyperplasia in 
which the lymphoid enlargement is associated with an increase of 
connective tissue. Where there is a considerable degree of redun- 
dance the mass appears in the form of folds with deep depressions 
or grooves (Fig. 448). In adults it is quite common to discover 
adhesive bands stretching from a central mass of adenoids to the 
tissues about the upper surface of the Eustachian orifice (Fig. 450). 
The enlargement usually reaches its height before the fif- 
teenth year, after which there is a moderate tendency to atrophy. 
Located deeply in the folds or recesses of the hyperplasia, cheesy 
masses made up of desquamated epithelium and other cell elements 
and bacteria are occasionally discovered. 

1 




U^T 




M IWiAi 



Fig. 434. — A group of five New York City public school boys, all of 
whom had adenoids and hypertrophied tonsils. (Photo loaned by the 
officials of the Health Department). 

Symptomatology. — The clinical picture in typical cases is charac- 
teristic. The listless expression, open mouth, pinched nose, thick 
lips, depression of the superior maxilla about the nasal orifices 
(Fig. 436), are sufficient to make the diagnosis clear. The victims 
are liable to suffer from conjunctivitis and inflamed palpebral 
margins. The nostrils are usually filled with thick mucus or muco- 
pus, which is difficult to remove on account of the inability of the 
patient to blow the nose. The lymphatic chain, either in front of or 
behind the sternocleidomastoid muscle, often becomes enlarged 
when the lymphoid structures of the oro- or naso-pharynx are 
infected. The chain in front of the sternocleidomastoid muscle 
draining the tonsil is perceptibly enlarged when the tonsil is 
infected, and the chain behind this muscle becomes enlarged when 
the adenoid structure of the nasopharynx is the seat of infection. 
The author has observed this particularly when cither tonsil or 
adenoid is tuberculous. 



670 



THE PHARYNX AND FAUCES. 



Through the courtesy of the officers of the Health Department 
of New York City the author is permitted to publish a series of 
photographs secured from children attending the public schools. 
The group shown in Fig. 434 were typical cases. Numbers 1, 2 
and 3 of this group are again shown in Fig. 435 after the removal 
of their tonsils and adenoids. The marked improvement in facial 
expression is well shown both in the above illustration and in Fig. 
437. 

A group of mentally defective children with adenoids is shown 
in Fig. 438, and it is affirmed that, after removal of their adenoids 
and tonsils and a short sojourn in the country, the entire number 
were able to keep up with their regular class work. 




Fig. 435. — Same boys as Nos. 1, 2, 3 of Fig. 434, after operation. 



There is a tendency to protrusion of the sternum, with more or 
less flattening of the chest walls. Subjectively, there is a history 
of mouth-breathing, snoring, restless sleep, night terrors, dull 
mentality, anemia, alteration in voice, frequent infections and colds 
which are prone to induce attacks of tracheitis, bronchitis, and 
recurrent purulent otitis media. In detail the symptoms are herein 
classified as follows: 1, symptoms resulting from the obstruction 
of nasal respiration ; 2, symptoms resulting from inflammatory 
changes in the lymphoid tissue of the nasopharynx and secondarily 
involving the mucosa of the nasal cavities, the middle ear, the 
pharynx, larynx, and bronchial tubes ; 3, reflex neuro&es sometimes 
induced by adenoids. 

1. Obstructed nasal respiration is present — at least to a mild 
degree — in all individuals who suffer from adenoids, and almost 
without exception they exhibit to a slight degree the typical 
changes in facial expression. Wide-open mouth-breathing during 
the waking hours occurs only in the severest cases (Fig. 436), but 
the lips and jaws are slightly separated most of the time in mild 



THE NASOPHARYNX. 



671 



cases. The nostrils are usually contracted and markedly depressed 
at the labial junction, and the labionasal fold is indistinct or absent. 
The upper lip usually protrudes. When asleep the mouth is widely 
open, respiration is labored, snoring is common, and night terrors, 
moaning and outcries are frequent. Adenoid patients are intensely 
restless during sleep ; they roll and tumble about the bed and kick 
off the covers. They often lie upon the stomach and chest, with 
the knees drawn upward underneath. They are extremely liable 
to take cold. under slight provocation, and their colds are prone to 
result in attacks of spasmodic croup, partially on account of the 
obstructed nasal respiration. The prolonged oxygen starvation 
which results from the abnormal and obstructed respiration is 
largely responsible for the retarded physical development, the 





Fig. 436.— The typical adenoid 
facial expression. (Photo loaned 
by the officials of the New York 
City Health Department.) 



Fig. 437.— Same boy as 
in Fig. 436, after the re- 
moval of adenoids. 



persistent anemia, the apparent stupidity and lack of mental con- 
centration (aprosexia). 

Young infants find great difficulty in nursing and are obliged 
to drop the nipple at frequent intervals in order to breathe. 

Disorders of digestion from swallowing the discharges, pyrexia 
from septic absorption from the growths, and anosmia and epistaxis 
are commonly observed. 

The nasal obstruction induces marked alteration in phonation, 
both as to character and tune, the voice being similar to thai which 
accompanies an aggravated cold in the head, so that the consonants, 
like m and n, arc pronounced eb, cd, etc. 

In severe cases which are unrelieved by timely operative 
interference, there is a marked tendency to deformity of the supe- 
rior maxillary bone, the characteristics of which are recession about 
the nasal orifices, contracted V-shaped arches, and irregularities of 
the teeth. 



672 



THE PHARYNX AND FAUCES. 



2. Inflammatory symptoms and complications : Children who 
have adenoids are particularly subject to acute infections of the 
nasopharyngeal mucosa. All acute intranasal inflammations, espe- 
cially those which accompany the exanthemata, grippe and other 
infections, are more deep-seated and prolonged. Furthermore such 
attacks may induce persistent and aggravating rhinitis, pharvngitis, 
laryngitis and bronchitis; catarrhal and purulent otitis media, and 
finally chronic pharyngitis, laryngitis and bronchitis, and deafness. 

Recurrent colds and persistent cough in a young .child should 
invariably lead to a suspicion of adenoids. A dull-red* liver-colored 
membrana tympani is quite common and characteristic in children 
who have adenoids. 




Fig. 438. — Group of "mentally defective children with adenoids." 
After the removal of adenoids and a short vacation in the country the 
greater number were thereafter able to keep up with their regular class 
work. (Photo loaned by the officials of the New York City Health De- 
partment.) 

In the majority of cases middle-ear complications are present. 
In an examination of 307 cases of adenoids McBride and Turner 
found 255 who had middle-ear lesions. Of the 255 cases 144 were 
purulent and 111 were more or less deaf from catarrhal otitis media. 

The attack upon the ear may be catarrhal or purulent. In 
either case the condition is serious, threatening partial or total loss 
of hearing, or some of the serious sequelae of middle-ear suppuration. 
It is the invariable rule that all children who have recurrent attacks 
of middle-ear suppuration have adenoids. According to Franken- 
berger, the percentage of adenoids in deaf-mutes is much higher 
than in the general run of children. He found adenoids in 94 out 
of 159 deaf-mutes, or 60 per cent. 



THE NASOPHARYNX. 573 

3. Reflex neuroses sometimes induced by adenoids: In addition 
to the nocturnal symptoms above described, epileptiform convulsions 
are occasionally noted and are more common at night. Daly and 
others have reported recoveries following operations for the removal 
of adenoids. Nocturnal incontinence of urine is also an occasional 
reflex disturbance. Stammering, chorea, hay fever, and asthma are 
aggravated if not caused by adenoids. Many adenoid patients are 
peevish, restless, and have marked inaptitude for mental activity 
(aprosexia). Mental sluggishness, however, is more apparent than 
real, often arising from the child's embarrassment at being gibed for 
his peculiar speech. A barking, croupy cough, worse at night, is a 
common complication of adenoids. 

Diagnosis. — In addition to the manifest symptoms, the diag- 
nosis of adenoid vegetations may be-verified by one or more of the 
following procedures: 1, anterior rhinoscopy; 2, posterior rhinos- 
copy, and, 3, digital examination. 

Anterior Rhinoscopy. — The nasal passages should always be 
scrutinized both for the purpose of ascertaining the extent of the inflam- 
mation and thickening of the mucosa, and also to exclude intranasal 
tumors, deformities or foreign bodies as a cause of the obstructed 
respiration. Occasionally it is possible to observe the masses of 
adenoids by anterior rhinoscopy. 

Posterior Rhinoscopy. — For actual demonstration posterior 
rhinoscopy or digital palpation becomes necessary. Of the two 
methods the former is preferable and can usually be conducted with- 
out difficulty. It is accomplished without pain, but requires much tact 
and considerable manual dexterity. The patient's confidence should 
first be secured and the use of each instrument fully explained in the 
following manner: 1, attract the child's attention by asking him to see 
his face in the head mirror ; 2, without instruments in hand ask him to 
open his mouth wide, keeping his tongue within ; 3, before introducing 
the tongue depressor explain that it is simply to press down the tongue 
in order that the throat may be seen, and, if necessary, the examiner 
should illustrate by pressing down his own tongue. After a little the 
child submits freely to this manoeuvre. The throat mirror should then 
be taken and the explanation made to the child that it is a looking-glass 
and is used only for the purpose of seeing; that it is warmed in order 
that the breath will not obscure the vision. The word "looking-glass" 
being fully understood even by very young patients, they permit its 
introduction without opposition. Now with the tongue depressed the 
patient should be encouraged at every step by saying, "You are doing 
well; I am beginning to see," etc., until the mirror falls well behind the 
velum (Fig. 15), when the adenoids come into view. The author 
rarely finds it necessary to make a digital examination. 

Digital examination is an extremely painful process and forever 
destroys the confidence of the little patient. ( Occasionally, however, it 
becomes necessary to employ it. The operator should Maud at the 
ide of iii'' patient, with the lefl arm thrown around die side of his 
head, tin- latter being firmly pressed againsl the examiner's hip. The 
child is instructed to open his mouth widely, at which time the fore- 

1:: 



674 



THE PHARYNX AXD FAUCES. 



finger of the left hand should press the side of the cheek and lip well 
into the mouth between the teeth and hold it firmly in that position until 
the entire examination has been completed. The finger-tip of the right 
hand is passed quickly against the posterior wall and thence forced 
upward into the vault, where a spongy, velvety mass is felt. It is 
impossible for the patient to bite the examiner's finger, providing the 




Fig. 439. — Denhart's mouth-gag. 

lips and cheek are continuously pushed between the child's open jaws 
on the left side. 

Differential Diagnosis. — Obstruction to nasal respiration from 
foreign bodies in the nose may be mistaken for adenoids. Malig- 
nant growths, while obstructive, always present their characteristic 
symptoms of rapid growth, pain, cachexia, hemorrhage, etc. 
Fibroma in the region of Luschka's tonsil is occasionally observed. 
It is more dense in structure than adenoids, with a smoother sur- 
face, and tends to recur. 




Fig. 440. — The Chapin tongue depressor. 



Prognosis. — When recognized early and promptly relieved by 
operation, the prognosis is good; on the other hand, if allowed to 
remain and become more and more diseased, serious results may be 
expected from the prolonged obstruction to nasal respiration as well 
as from the various infections which are prone to attack the nose 
and nasopharynx. Added dangers are attacks of purulent otitis 
media, acute infectious diseases, bronchitis, pneumonia, superior 
maxillary and chest deformities and deafness. If thoroughly re- 
moved by operation the tendency to recurrence is practically nil, 
less than 5 per cent. After the fifteenth year the growths tend to 
gradual atrophy, but too late to prevent the more serious complicating 
lesions. 



THE NASOPHARYNX. 



675 



Treatment. — The treatment of this affection is surgical. If the 
growths are present in sufficient amount to cause even one of the 
symptoms above enumerated, they should be removed. Often the 
ear symptoms seem to be more prominent than those associated 
with nasal respiration. In these cases also the operation becomes 
imperative. Early recognition and prompt and thorough surgical 
removal should be the invariable rule. Local applications and internal 
medication are palliative, but are applicable in that very small per- 
centage of cases wherein the child has a catarrhal tendency, with but 




Fig. 441. — The Brandegee adenoid forceps. 



slight lymphoid hyperplasia. In such cases the internal administration 
of iron, cod-liver oil and arsenic, in conjunction with thorough daily 
cleansing of the nose and nasopharynx, may check the tendency to 
lymphoid hyperplasia. In like manner the hygienic and other 
measures recommended for acute rhinitis (Chapter XXXIII) are 
applicable here. In the majority of cases the operation is performed 
in conjunction with the removal of the tonsils. The tendency, both 
on the part of the medical profession and the laity, is to under- 
estimate the gravity of the combined tonsil and adenoid operation 
when properly performed. It is attended with severe hemorrhage — 




Fig. 442.— The Beckn 



more severe than that which occurs in many capital operations. The 
operation is also extremely painful. Local anesthesia, while never 
entirely relieving the pain, is sometimes feasible in adults. In 
children, however, the general anesthetic should lie employed, except 
in cases where for cardiac, glandular or other reasons the anesthetic 
would he dangerous. Whenever possible the operation should he 
performed in a hospital, where the patient should remain for from 
twenty-four to forty-eighl hours, thus avoiding the dangers from 
secondary hemorrhage or the complications arising from the anes- 
thetic. The details of the operation arc a- follows: — 

Preparation of the Patient.- The preparation of the patient 
consists in administering a mild cathartic on the previous night, and 
the cleansing of the nose and nasopharynx with a saline solution twice 



676 



THE PHARYNX AND FAUCES. 



daily for twenty-four hours. When the operation is to he performed 
in the afternoon the patient may be permitted to drink a glass of milk 
or take a small portion of soft food at breakfast time, but for morning 
operations no food should be taken. The anesthetic should be adminis- 
tered by one experienced in anesthetizing children for the adenoid 
operation, such experience covering the degree of anesthesia, the 
manipulation of the mouth-gag, maintaining the position of the 
head, the removal of blood, and the necessary watch-care for the few 




Fig. 443. — The Stubbs adenoid curet. 



minutes subsequent to the operation. It is inadvisable to allow 
inexperienced anesthetists to administer anesthetics for this 
operation. 

Generally speaking, ether is the safest anesthetic. It is possible, 
and often feasible, to operate with nitrous-oxid-gas anesthesia in cases 
where the tonsils do not require attention. 

With the mouth, nose and face thoroughly cleansed, a sterile-rub- 
ber cap should be put upon the head, over which should be pinned a 
sterile towel; otherwise the preparations are similar to those for all 
operations upon the nose and throat. 




Fig. 444. — The Coffin small curved adenoid ring curet. 

To cover all necessities and emergencies the following armamen- 
tarium of instruments and remedies should be at hand, in addition to 
those required by the anesthetist : — 

Mouth gag (Fig. 439) ; tongue depressor (Fig. 440) ; adenoid for- 
ceps (Fig. 441) ; adenoid curets ; sponge holders (Fig. 449) ; small 
pair of forceps for removing adenoid from mouth ; tonsil punch 
I Fig. 477); gauze sponges; adrenalin; ice-water. 

Numerous instruments have been devised for the removal of 
adenoids, the two general types being the forceps and the curet, many 
varieties of each being extant. Of the various modifications of adenoid 
forceps that of Brandegee (Fig. 441) is the best adapted for the 



THE NASOPHARYNX. 



677 



adenoid operation. The Beckman adenoid curet (Fig. 442) is adapta- 
ble in very young children, but lacks sufficient reach in older children 
and adults. The Stubbs modification (Fig. 443), by possessing a 
downward curve at the junction of the shank and the cutting ring, 
enables the surgeon to reach and encircle the uppermost parts of the 
growth. Hence this curet is recommended. 




Fig. 445. — Position of patient, operator, and assistants for removal of 
adenoids and tonsils under general anesthesia. (Photographed in the 
Manhattan Eye, Ear, and Throat Hospital operating room.) 



The small ring curet devised by Coffin (Fig. 444) is of great 
service for the purpose of removing residual shreds, or small masses 
of adenoids which are beyond the reach of the larger curets or forceps. 

Position of the Patient. — The consensus of opinion among 
American rhinologists favors the dorsal position for adenoid and tonsil 
operations (Fig. 445), when general anesthesia is employed. The 
patient's head should be slightly lowered or turned to one side during 



678 



THE PHARYNX AND FAUCES. 



the procedure in accordance with the adaptability of the individual 
surgeon. The upright position is preferable when local anesthesia is 
chosen, inasmuch as under these conditions the patient is able to avoid 
the inhalation of blood. 

Furthermore the operation should be performed under bright 




Fig. 446. — The Thomson protector for the adenoid curet. 

illumination. The electric headlight (Fig. 5) is most satisfactory for 
operations upon adenoids and tonsils. 

Operation with the Curet. — In the majority of cases the curet 
should be relied upon for the removal of the mass of adenoids. With 
a sharp curet, well selected as to size and adaptability, the entire mass 
may be completely excised with a single sweep and without injury to 




Fig. 447. — Schematic representation of the removal of adenoids by 
means of the curet. 



the surrounding tissues. It is of the utmost importance that the curet 
should be sharp, and to this end the protector devised by Thomson 
(Fig. 446) guards the cutting edge from contact with other instru- 
ments. 

Having selected the curet, it should be introduced behind the soft 
palate into the postnasal space. Some authorities advise the employ- 
ment of a palate retractor (Fig. 16) during this procedure, but in 



THE NASOPHARYNX. 



679 



skillful hands no retractor is needed. The curet should be carried 
upward and backward until it comes into contact with the posterior 
border of the choanal, when, by tilting the handle upward and at the 
same time firmly forcing the blade into position against the upper line 
of the posterior wall, its ring is made to encircle the growth. With a 
firm, downward, sweeping movement the curet is made to sever the 
entire mass at its base of attachment (Fig. 447), but the cutting should 
terminate at the lowest point of attachment of the adenoids. Further- 
more, the blade should not penetrate the submucous structures or 
denude the underlying bone. 

The severed mass of tissue (Fig. 448) usually falls into the mouth 




448. — Large adenoid, actual size, showing linear folds 
and deep depressions. 



upon the withdrawal of the curet, but it shouM be carefully watched 
for and grasped with forceps in order to avoid being accidentally drawn 
into the larynx. Before concluding the procedure the postnasal space 
should be palpated with the finger, and any remaining shreds removed. 
Whenever such shreds are attached to the posterior pharyngeal wall, 
by lifting the soft palate they are easily cut away with a tonsil punch. 
It sometimes becomes necessary to employ the adenoid forceps (large 
or small) to complete the operation. 

Operation with the Forceps. — The Brandagee forceps (Fig. 
441 ) should be selected. There are two sizes. This instrument fits the 
vault, has a wide cutting surface, and with one cut it is usually possible 
to remove the mass. The anesthetist or assistant should hold the 
patient's head firmly and the adenoid forceps, closed, should be 
carefully introduced into the nasopharynx, and gently rotated to 



680 



THE PHARYNX AXD FAUCES. 



free the jaws from possible attachment to the membrane of the 
A-elum. The distal end should then be carried firmly against the 
extreme portion of the vault and as close as possible to the choanae. 
The jaws should then be widely separated and pressed against the 
vault with sufficient force to engage the growth. Before cutting, 
the shank of the forceps should be brought into a position touching 
the upper incisor teeth, exactly in the median line. This precaution 
prevents the accident of grasping the posterior border of the vomer. 
The jaws of the forceps should now be tightly closed. The closing 
of the jaws of the forceps does not fully cut through the mass, and 
one or two rocking movements should be made, with force sufficient 
to partly cut and partly tear off the adenoids, before it is drawn 
downward into the mouth ; otherwise there is danger of stripping 
the membrane from the posterior pharyngeal wall. As a rule it is 
necessary to complete the removal with the curet or finger, prefer- 
ably the former. The hemorrhage is profuse, but usually is not 




-Th 



persistent. The patient should be rolled upon his side and under 
good illumination the blood should be removed by means of swabs 
held in large sponge holders (Fig. 449). 

When the finger is introduced, either for the purpose of 
determining whether the removal is complete or to scrape away rem- 
nants of adenoids, it should be encased in a layer of sterile gauze, 
which may be saturated with alcohol, the latter being both astringent 
and styptic. 

After completing the operation, the patient should be rolled upon 
his side and his face swathed with towels well soaked with ice-water 
until the hemorrhage has practically ceased. The hemorrhage is 
usually self-limited and rarely persists after the first few seconds. 
Several procedures have been devised for controlling the hemor- 
rhage. 

As the hemorrhage ceases, the mouth gag may be removed and the 
patient carried to his room, where he should be continuously watched 
until he recovers from the anesthetic and all danger of hemorrhage 
has passed. After returning the patient to bed, the position upon 
the side or stomach is preferred. Patients should lie upon the side 
for some time. If allowed to lie upon the back they may swallow 
blood without giving evidence of hemorrhage. 



THE NASOPHARYNX. 



681 



In case of severe and persistent postoperative hemorrhage pres- 
sure must be applied to the bleeding point. Masses of absorbent 
cotton or gauze dipped in adrenalin solution and grasped in strong 
curved forceps should be passed up behind the velum with suffi- 
cient pressure to control the hemorrhage. Persistent hemorrhage 
occasionally yields only to hypodermics of human or horse serum or 
to anterior and postnasal plugging. The latter procedure often in- 
duces attacks of purulent otitis media. In one of the author's cases 
it was necessary to resort to anterior and postnasal plugging on 
three occasions during the six days following an adenoid operation, 
and in spite of the utmost care the patient developed acute purulent 
otitis media, and, finally, an attack of acute mastoiditis. 

After-treatment. — There is but slight pain following the ade- 
noid operation unless a tonsillotomy has been performed, when the 




Fig. 450. — The adhesive bands pass from a central adenoid mass to the 
upper surface of the orifice of the Eustachian tubes. 

pain is chiefly referable to the cut surfaces of the tonsils. There is 
but slight reaction and only occasionally any acute inflammatory stage, 
except in those rare cases where some latent infection is present, when 
there may be considerable discomfort. The patient should remain in 
bed for from twenty-four to forty-eight hours, and the temperature 
taken. If on the following day the temperature is normal and there 
is no apparent reaction, the patient may sit up in bed toward night, and 
the following morning be allowed to put on ordinary clothing and be 
up and about the house, but he should be restrained from overexertion 
of any kind and if possible from going into vitiated air or contaminated 
atmospheres. Children should not be allowed to return to school for 
several days on account of the danger of infection. Local applica- 
tions are usually unnecessary, but, when some cleansing wash is 
required, a spray of an alkaline antiseptic solution will suffice. Medica- 
ments locally applied should be avoided. The nasopharyngeal space 
should be carefully re-examined at the end of one or two weeks in 



682 



THE PHARYNX AXD FAUCES. 



order to ascertain whether the entire growth has heen removed. No 
subsequent treatment is required beyond the daily performance of 
intranasal hygiene (see Chapter XXXIII) whenever purulent secre- 
tions continue. 

As soon as normal nasal respiration is established these patients, 
even without internal medication., immediately begin to show the 
beneficial effects of proper oxygenation. The color improves, the 
anemia disappears and the bodily weight rapidly increases. In one of 
the author's cases which was complicated by deflected septum, in a 
stunted, anemic, pigeon-breasted boy of sixteen years of age, the sep- 
tum was straightened, the adenoids and tonsils were removed, and 
during the following year he gained about forty pounds in weight. 

Adhesive bands in the nasopharynx (Fig. 450) should be cut 
away or otherwise destroyed. The author has devised a guarded 
galvanocautery knife (Fig. 451 ), which may be introduced behind 
the adhesive band in a manner similar to that of the probe in Fig. 




-The author's galvanocautery knife for dividing 
adhesions in the nasopharynx. 



450, after which the current is turned on and a segment of the band 
destroyed. These and other postnasal and nasopharyngeal growths 
are easily demonstrated by means of the pharyngoscope (Fig. 494). 

Recurrence. — Adenoids rarely recur after complete removal. 
The so-called recurrences in the majority of cases occur where the 
primary operation has been incomplete. In infants and children 
under four years of age, additional lymphoid glands may undergo 
inflammatory changes, and coalesce into obstructive masses of 
sufficient size to require operation. 

Syphilis of the Nasopharynx. — The phenomena of both second- 
ary and tertiary syphilis are observed in the nasopharynx, in the 
form of mucous patches or gummata. Syphilis of the nasopharynx 
is fully described in Chapter XXX. 



NEOPLASMS OF THE NASOPHARYNX. 

Benign Neoplasms. 

Benign neoplasms of nasopharyngeal origin are extremely rare. 
They are chiefly confined to the myxomatous and fibromatous varieties, 
but cases of papilloma, enchondroma and lipoma have been recorded. 



THE NASOPHARYNX. 683 

Nasopharyngeal Polypi. 

Primary nasopharyngeal polypi should be differentiated from those 
which have protruded into this space from their attachment in the 
nares (see Chapter XLII). 

Etiology. — Nasopharyngeal polypi are commonly associated 
with nasal polypi, and are similar in pathology, etiology and symp- 
toms. They are prone to appear in early life and are somewhat 
more common in males. They are usually denser in structure, 
hence are less edematous and often attain large size. 

Treatment. — For treatment see Nasal Polypi, Chapter XLII. 

Nasopharyngeal Fibromata. 

Etiology. — The exact cause of nasopharyngeal fibromata is 
unknown. The typical nasopharyngeal fibroma springs from the 
basilar fibrocartilage, but may originate from the anterior surfaces 
of the upper cervical vertebrae and in the sphenopalatine fossa. 
The characteristics of these growths are: 1, extreme hardness, so 
that the knife or snare wire often cuts through them with diffi- 
culty ; 2, tendency to extensive growth and to invade the surround- 
ing tissues, especially the nasal cavities, the cheek or orbit ; 3, naso- 
pharyngeal fibromata are destructive, inasmuch as they push aside 
and erode the walls of the cavities in which they are lodged and 
ultimately reach the cranial cavity; 4, the continued pressure and 
friction result in rupture and, later on, cicatricial adhesions form 
between certain portions; 5, vascular erosion is a common result, 
and any violence, such as sneezing, blowing the nose, etc., is liable 
to be followed by severe hemorrhage ; 6, tendency to recur after 
removal. 

Symptoms. — The early symptoms are similar to those of naso- 
pharyngeal polypi with the exception of their tendency to hemor- 
rhage. When unrelieved by operation they cause erosions and pain 
by pressure, and later on deformity to the parts and free muco- 
purulent discharge. 

When left to itself the disease usually terminates in death 
through asphyxia, inanition or cerebral lesions. Occasionally, 
however, spontaneous involution of the neoplasm has been 
observed, with complete subsidence. These tumors are benign 
growths, inasmuch as they do not give rise to metastases and do 
not destroy the neighboring tissues by a process of infiltration, but 
are harmful by causing mechanical displacement. 

Prognosis. — When operated upon while small the prognosis is 
fairly good. There is a marked tendency to recurrence. Whenever 
the growth has extended to the surrounding cavities, especially in 
the brain, the prognosis is bad. 

Treatment. — When of moderate size they should be removed 
with a cold-wire or galvanocautery snare. This method of treat- 
ment greatly simplifies the removal of fibromata, and furthermore 
possesses the advantage that general anesthesia is not required. 



684 THE PHARYNX AXD FAUCES. 

Removal with the snare is difficult on account of the density 
of the tumor and the tendency to violent hemorrhage. 

Extensive surgical procedures under general anesthesia are 
necessary to remove large fibromata. Among the radical opera- 
tions Kocher splits the entire roof of the mouth, separating the 
superior maxilla, and so gains room enough to remove the large 
neoplasm from the nasopharynx. Pharyngotomy sometimes be- 
comes necessary. 

MALIGNANT NEOPLASMS OF THE NASOPHARYNX. 

Sarcomata. 

Primary sarcoma of the nasopharynx is rare, but sarcomatous 
growths may spring from the roof of the pharyngeal vault ; more 
rarely along the lateral or posterior walls. They usually extend from 
the nasopharynx into nasal cavities, and break through the walls of the 
orbit, antrum or cranial cavities. Sarcoma of the nasopharynx 
occurs in both adults and children. 

Lymphosarcomata. 

Lymphosarcoma also occurs primarily in the nasopharynx. At 
the onset it appears as a swelling of the adenoid tissue, but it rapidly 
degenerates and ulcerates. There is always marked anemia and 
cachexia, and the disease invariably terminates fatally in a few 
months from exhaustion, inanition or asphyxia. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — The treatment of sarcoma and lymphosarcoma is 
palliative and is resorted to for the relief of distressing pressure symp- 
toms. Surgical removal of portions of the growth is sometimes under- 
taken for the purpose of re-establishing drainage and the relief of 
pain. The internal administration of large doses of arsenic in the 
form of Fowler's solution has been recommended. Trypsin and other 
similar remedies (see Chapter XLII) have not produced encouraging 
results. 

Carcinomata. 

Primary carcinoma of the nasopharynx is exceedingly rare and 
much less common than sarcoma. The point of origin is usually in the 
superior pharyngeal wall, from which the growth extends to the 
surrounding structures, especially the soft palate and pharynx. 
They develop rather slowly, pain is not severe until pressure occurs, 
and hemorrhage is less common and constant than in sarcoma. 

The diagnosis is dependent upon the microscopic findings, but 
the symptoms are fairly characteristic. 

Prognosis. — The prognosis, even when operation is resorted to, 
is unfavorable, and recurrence is the rule. The patients usually 
succumb to exhaustion after months of intense suffering. 

Treatment. — In the earlier stages radical removal may be at- 
tempted and may result in prolonging life, but the growths almost 
invariably recur. The pain should be relieved by morphine. 



THE NASOPHARYNX. • . 685 



Teratomata. 

Tumors of this class are congenital, and when occurring in the 
nasopharynx seldom attain any considerable size. Their attachment is 
sometimes so slender that they become detached spontaneously. 
One case has been reported in which the child swallowed the tumor, 
voiding it next day per rectum. They have been known to project 
into the floor of the pituitary fossa, thereby causing compression of 
the optic tract and nerves. 

FOREIGN BODIES IN THE NASOPHARYNX. 

Masses of food or of harder substances occasionally become 
lodged in the nasopharynx as a result of vomiting or regurgitation. 
This accident is particularly liable to befall those who have paral- 
ysis, especially children with postdiphtheritic paralysis. Bullets 
and other projectiles may also find lodgment in this location. 




Fig. 452. — The Hooper adenoid forceps. 

Symptoms. — Sudden obstruction to nasal respiration following 
an attack of vomiting is generally the first symptom noted. Smaller 
substances give rise to an uncomfortable stuffy sensation, the 
patient usually ascribing it to something in the upper part of the 
throat. 

Diagnosis. — In addition to the characteristic symptoms, the 
diagnosis is made by rhinoscopic or digital examination. Cocaine 
should be freely applied to the surrounding tissues in order to allay 
the reflex irritation. Quite often the foreign body is visible below 
the border of the soft palate, or can be seen by introducing a palate 
retractor. 

Treatment. — Removal with forceps is the usual method em- 
ployed. The small Hooper adenoid forceps (Fig. 452) are adaptable 
for this purpose, inasmuch as this instrument conforms well to the 
pharyngeal vault. The procedure is usually comparatively simple 
in experienced hands, and can be carried out without the induction 
of general anesthesia. 



CHAPTER XLIV. 
DISEASES OF THE OROPHARYNX. 



I. SURGICAL ANATOMY. 

The oropharynx or "pharynx proper" (Fig. 18) lies below the 
level of the soft palate and is thus distinguished from the naso- 
pharynx. It has no anterior wall, inasmuch as this space constitutes 
its avenue of communication with the mouth (Fig. 431). The 
posterior wall is formed by a portion of the cervical vertebrae (chiefly 
of the body of the axis), and of the longus colli and recti capitis 
anticus muscles. It is nearly flat under normal conditions. The 
lateral walls are made up of loose connective tissue and the con- 
strictor muscles of the pharynx, these structures at the same time 
protecting the large blood-vessels of the neck. The mucosa is 
similar to that of the nasopharynx, but is lined with stratified epi- 
thelium. Nodules of lymphoid tissue are scattered over the oro- 
pharynx, especially the posterior wall, and a chain of lymph-nodules 
on the lateral walls is continuous with the lymphoid tissue of the 
nasopharynx. 

The soft palate, also known as the velum palati, is made up of 
two layers of mucosa, between which muscle fibres are interposed, 
and it is attached to the posterior border of the hard palate. A 
median, anteroposterior raphe marks the line of attachment of the 
two lateral halves. A conical-shaped prolongation of this line at 
the lower border is known as the uvula. The lateral portions of 
the free border arch downward and divide into two folds, one -of 
which contains the palatoglossus muscle and is attached to the 
lateral margin of the tongue. This fold constitutes the anterior 
pillar of the fauces. The remaining fold contains the palato- 
pharyngeus muscle, which is inserted into the lateral and posterior 
wall of the oropharynx. This fold forms the posterior pillar of the 
fauces. 

The Tonsils. — The faucial tonsils, two in number, are deeply 
located between the anterior and posterior pillars of the fauces, on 
either side. They are largely composed of lymphoid tissue sup- 
ported by a framework of connective tissue, and the exposed sur- 
faces, even of the crypts, are covered with mucous membrane. The 
outer surface (base) is sheathed in a fibrous capsule which rests 
upon the superior constrictor muscle. Normally the tonsils do not 
project beyond the pillars of the fauces and are invisible by ordinary 
inspection. The tonsil receives its blood-supply chiefly from the 
tonsillar branch of the facial. It is further supplied by the dorsalis 
linguae from the lingual, the ascending palatine, the ascending 
pharyngeal from the external parotid, and finally from the descend- 
ing palatine artery. 
"(686) 



DISEASES OF THE OROPHARYNX. 687 

When slightly diseased or hypertrophied, canals or crypts ap- 
pear in the glandular substance. As the hypertrophy increases, the 
tonsil projects beyond the borders of the pillars into the pharyngeal 
space, the surfaces being studded with lacunae, which serve as 
openings for the crypts. 

The Lingual Tonsil. — Along the posterior border of the tongue, 
between the circumvallate papillae and the epiglottis, is located the 
so-called lingual tonsil, which .is made up of a conglomerate mass of 
lymph-glands. These are visible only when. the lymphoid tissue is 
hypertrophied. Histologically, the lingual and faucial tonsils are 
identical. Occasionally a mass of distended and varicose veins 
occupies this site and is designated as lingual varix. Enlargement 
of the lingual tonsil and varix often gives rise to reflex throat 
symptoms. 

The Tongue. — The tongue may present asymmetry, cicatrices, 
or impaired motility as a result of various neuroses, and it is also 
subject to a number of pathological conditions, such as ranula, lupus, 
cancer, syphilis and leprosy. It varies within wide limits in regard 
to size, surface, and firmness of texture, while its color and secre- 
tion afford a fair index to the general health of the individual. 

The lingual artery passes forward on the tongue, close to the 
lower end of the faucial tonsil, where it may readily be compressed. 
In operations on the faucial tonsil, whether from within or from 
without, the direct vicinity of the carotid arteries as well as the 
ascending pharyngeal and ascending palatine vessels is of much 
surgical importance. The palatine muscles assist in the move- 
ments of swallowing and also participate in the production of the 
voice. The tensor and levator palati muscles influence the auditory 
function on account of their relation to the Eustachian tube. 

An important function of the soft palate, aided by the palatine 
arches and the uvula, is the closing off of the middle pharyngeal 
space from the upper portion of the pharynx during the act of 
swallowing. The various diseases of the oropharynx and velum 
very commonly give rise to disturbances of swallowing; less fre- 
quently of speech, and rarely of respiration. 

The oropharynx communicates with the buccal cavity through 
the faucial isthmus, the circular boundaries of which are repre- 
sented by the velum palati, the faucial arches and the base of the 
tongue. 

To inspect the entire oropharynx, including the posterior wall, 
the two lateral walls and the velum, involves the employment of a 
pharyngeal mirror and the tongue must be depressed and the velum 
relaxed. 

The mucosa of the posterior and lateral walls is normally of a 
more vivid red than that found in the buccal cavity. As a rule it 
is smooth, moist and glistening, but it may presenl a somewhat 
roughened and uneven appearance without being diseased. A 
number of more or less distinct blood-vessels traverse the posterior 
pharyngeal wall. Pathological conditions involving this area tend 
to progress either toward the nasopharynx or toward the larynx. 



688 THE PHARYNX AND FAUCES. 

Under normal conditions moderately enlarged pharyngeal tonsils 
begin to undergo involution about the age of puberty, the process 
usually beinsr concluded at about the twenty-fifth year. 



II. MALFORMATIONS AND DEFORMITIES OF THE 
OROPHARYNX. 

The malformations observed in the oropharynx are : stenosis, 
dilatation (pharyngocele) or diverticula, and asymmetry. Of these 
the most common is stenosis, which may occur as a congenital 
condition or secondarily as a result of injury to or inflammation of 
the surrounding structures. Congenital atresia is very rare, and 
but few cases of complete atresia have been reported. Cases of 
partial atresia are more common. Reports of complete closure 
have shown that the atresia occurs in conjunction with pouches. 
Stenosis when following inflammatory diseases or injury is due to 
cicatricial contraction. Syphilis furnishes by far the larger pro- 
portion of this class of cases. Adhesion of the velum to the 
posterior pharyngeal wall (Fig. 285), with the attendant contrac- 
tions, leads to a variety of pharyngeal deformities, many interfering 
with the act of deglutition, and all characterized by more or 
less interference with nasal respiration. These adhesions some- 
times extend well up into the nasopharynx or downward into the 
laryngopharynx, where the scar tissue and adhesions prove most 
troublesome. Traumatism usually results from the accidental 
ingestion of scalding or caustic fluids. Cases of this class often 
result fatally before a permanent stenosis has developed, but edema 
is present during the acute inflammatory period. Spasm of the 
pharynx occasionally occurs in neurotic individuals or as a result of 
the bolting of food. 

Another form of stenosis, described as the extrinsic variety, 
results from outside causes which produce a partial closure of the 
pharyngeal lumen. Diseases of the vertebral column, deformities 
or forward curvature of the spine or twisting of the vertebrae, are 
liable to infringe upon the pharyngeal space. In like manner retro- 
pharyngeal abscess, marked enlargement of the lateral lobes of the 
thyroid gland, peritonsillar abscess, together with Hodgkin's 
disease, rbinoscleroma and the various malignant growths, may 
produce the extrinsic form. 

Diverticula or Dilatations of the Pharynx. 

Unless congenital, these are usually found as a result of 
mechanical causes, such as distention from the bolting of large 
masses of unmasticated food. This form is rarely observed in 
early life ; it comes on in consequence of the loss of teeth or the 
prolonged habit of bolting. Large pouches or dilatations are 
known as pharyngocele. The condition is occasionally congenital, 
when it is associated with atresia. In the author's cases the 
diverticula have invariably occurred in the upper portion of the 



DISEASES OF THE OROPHARYNX. 



689 



esophagus. Whenever a pharyngeal pouch is large and becomes 
temporarily filled it commonly produces a tumor-like external 
prominence which may be felt upon palpation. Patients are some- 
times able to disgorge the contents of the sac by pressure from 
without. A form of treatment recommended in severe cases is the 
application of a properly fitted pad over the site of the tumor. In a 
case now under treatment the diverticulum is small, but it is still 
of sufficient size to interfere with "large masses of food when 
hurriedly swallowed." 

Treatment. — The food should be largely of liquid or semi- 
liquid consistency and should be swallowed slowly. The occasional 
introduction of large esophageal bougies, by overcoming constric- 
tion above or below the pouch, is thereby of distinct advantage. 




Fig. 453.— Bifid uvula. 

Asymmetry of the Pharynx. 

This usually results from some abnormal or unusual promi- 
nence of vertebra or from exostoses of underlying bone. Cervical 
curvature or twisting of the vertebrae may reduce the calibre of the 
pharynx and give rise to some distress upon swallowing. These 
conditions are only to be found with retropharyngeal abscesses, or 
some form of tumor. A digital examination is usually sufficient to 
make the diagnosis complete. 

III. MALFORMATIONS AND DISEASES OF THE UVULA. 

The uvula admits of considerable variation in size under normal 
conditions. Congenital malformations, however, do occur, the chief 
of which are known as bifid uvula (Fig. 453), wherein the median 
elongation is divided into two portions usually of equal size. The 
extent of the bifurcation varies, but may be sufficiently deep to give the 
appearance of double uvula. This condition is undoubtedly analogous 
to congenital cleft of the soft palate. The rudimentary uvula is a form 
of malformation in which the uvula is only slightly developed 
and occasionally is absent altogether. Xo special symptoms are 
manifest in either of these conditions, nor do they cause annoyance 
or discomfort to the patient. 

Treatment. — If desired the bifid form may be operated upon 
by scarifying the opposing edges and uniting them by sutures. 



690 THE PHARYNX AND FAUCES. 

Elongation of the Uvula. 

■ Elongation of the uvula beyond the limitations of the normal 
may or may not be attended by pathological changes in the tissues 
and by characteristic symptoms. 

Etiology. — The condition is sometimes congenital, consisting of 
a redundancy of apparently normal tissue. In other cases relax- 
ation occurs, usually attended with anemia, which involves the soft 
palate as well. Partial paralysis occurring as a sequela of scarlet 
fever or diphtheria may give rise to the appearance of elongation 
of the uvula. Another form of elongated uvula is observed in 
connection with acute and chronic inflammations of the tissues 
of the upper air passages. Furthermore, elongation of the uvula, 
together with general relaxation of the soft palate, is commonly 
associated with the various digestive disturbances, which are 
grouped under the general heading of dyspepsia. 

Abscesses or other tumors, when they develop in the surrounding 




Fig. 454. — The McKenzie uvulotome. 

tissues, may force the uvula downward, and in so doing the latter 
usually becomes edematous. 

Symptoms. — The chief symptoms induced by elongation of the 
uvula are a tickling sensation in the fauces, cough, and in extreme cases* 
considerable interference with deglutition. Where the elongation 
amounts to two inches or more (Fig. 487) the patient literally swallows 
the uvula. The cough is aggravated by the recumbent position. 

Diagnosis. — Upon examination the uvula may be simply 
elongated, without much change in its lateral dimensions. The tip 
often extends downward into the glossoepiglottic space. 

Treatment. — When the elongation is considerable and gives 
rise to the symptoms above mentioned, the rational treatment consists 
in the surgical removal of the redundant portion. Astringent sprays 
or applications of adrenalin chlorid sometimes produce a temporary 
retraction. In every instance a careful examination of all adjacent 
tissue? should be made in order to ascertain any primary cause other 
than congenital. Relaxation associated with temporary paralysis 
requires the benefits of the internal administration of blood-building 
agents, together with outdoor life and the most nutritious food. 

Surgical Removal. — Excision is accomplished as follows : After 
carefully cleansing the entire mucosa of the oropharynx, the uvula 
should be anesthetized by painting with a 10 per cent, solution of 
cocaine. It is never wise to remove the entire uvula, the removal 
of the redundancy being all that is required. While several instru- 



DISEASES OF THE OROPHARYNX. 



691 



ments have been devised for this operation, notably the uvula 
scissors or some form of uvulotome (Fig. 454), the procedure is quite 
as well accomplished with a pair of ordinary long-handled scissors 
slightly curved upon the flat, the tip of the uvula meanwhile being 
grasped with suitable forceps. The tongue should be depressed, and 
the cut should be slightly slanting, the anterior portion of the uvula 
being left longer than the posterior. Less pain and irritation follow 
this form of excision, for the anterior dependent membrane serves 
to protect the wound during the act of swallowing. Stitches are of 
no benefit. As a rule, but slight hemorrhage is encountered, 
although at times bleeding persists for some time. Cases of alarm- 
ing hemorrhage have been reported. A gargle or the application 
of adrenalin chlorid is usually sufficient to control ordinary hem- 
orrhage. If it should persist, temporary clamping with forceps, 
ligation or cauterization may be resorted to. These procedures are 
not difficult. 




Fig. 455. — Edema of the uvula, with small punctures for the 
removal of serum. 

After-treatment. — Considerable inflammatory reaction follows 
the operation, and severe pain ensues, which is aggravated during 
deglutition. Soft food with but little seasoning should constitute 
the diet for a day or two following the operation. The surfaces 
may be kept clean by means of warm gargles of normal salt solution 
or a weak solution of formaldehyd. 



Acute Uvulitis. 

Etiology. — The texture and exposed location of the uvula 
render it peculiarly liable to injury, inflammation and edema. These 
affections commonly result from extension of adjacent inflamma- 
tions or from such injuries as cuts from sharp objects, such as fish- 
bones, or from scalds or burns. .Specific ulceration is not uncom- 
mon, and the edematous variety (Fig. 455) sometimes occurs as a 
result of the pressure from the encroachment of tumors. These 
may be benign, in the form of abscess or specific gummata, or malig- 
nant. Certain cases seem to occur as a result of diathesis or errors 
of digestion. 

Symptoms. — A tickling, stinging, painful sensation, aggravated 
by attempts at swallowing, is the first symptom observed. As the 



692 THE PHARYNX AND FAUCES. 

swelling- and edema increase, owing* to the infiltration of serous 
exudate into the soft, yielding tissues, the uvula tip becomes bulbous, 
elongated, and impinges upon the base of the tongue and epiglottis. 
The irritation thus induced evokes a persistent cough. In extreme 
cases respiration may be seriously obstructed, especially when in the 
recumbent posture. 

Diagnosis. — On the site of the uvula a large, boggy, inflamed, 
often edematous pendant mass will be observed, partially filling the 
oropharyngeal space. The edematous portions are usually found about 
the tip and posterior surfaces. 

Treatment. — In moderate cases during the early stages before 
edema appears, frequent gargling with glycerid of tannin, 1 dram to 
the ounce, is advisable. In edematous cases topical applications are 
without avail, and serum should be removed by simple puncture 
(Fig. 455) of the tissues, under cocaine anesthesia. In puncturing, 
care should be taken to avoid injury to the posterior pharyngeal 
wall. A sharp-pointed bistoury is the most convenient instrument. 
With this, from five to fifteen punctures are often necessary in 
order to drain the tissues, relieve the pressure, and thus enable the 
blood-vessels to carry off the remainder of the exudate. Before 
making the incisions the entire oropharynx should be thoroughly 
cleansed by means of sterile salt douche or gargle. It is sometimes 
necessary to repeat the punctures daily for two or three days. A 
gargle containing 1 to 3 grains of sulphate of copper to the ounce 
of water or a hot normal salt solution is beneficial. These tend 
to aid in the process of repair, and at the same time maintain proper 
cleanliness. When associated with abscesses, inflammations or 
tumors of the surrounding tissues, the latter affections must also be 
subjected to appropriate treatment. 

Free catharsis at the commencement of the attack tends to 
lessen its severity, shorten its course and minimize the edema. 
Whenever the disease is due to errors of digestion or assimilation it 
is incumbent upon the surgeon to submit the patient to a thorough 
examination of the entire digestive tract, the heart, blood-vessels and 
kidneys. 

IV. ULCERATIONS AND ADHESIONS. 

Ulcerations and adhesions of the uvula and soft palate usually 
result from tertiary syphilis. The superficial ulceration of the mu- 
cous patch occasionally involves this region, but without destruc- 
tion of the deeper tissues. The ulcerations associated with tertiary 
syphilis are most destructive not only in the loss of tissue, but from 
the ravages of the cicatricial tissue, which is prone to bind the 
remaining portions of the uvula and soft palate to the posterior 
pharyngeal wall (Fig. 285). When observed early the gummatous 
ulceration yields to the usual specific treatment. But after adhe- 
sions have formed they remain and stubbornly resist treatment. 
Occasionally some relief may be obtained by dividing the cicatricial 
bands. The adhesions vary in form and extent, from a partial adhe- 
sion of one pillar, to a complete attachment of the soft palate which 



DISEASES OF THE OROPHARYNX. 693 

closes the nasopharyngeal channel. While for the most part these 
adhesions occur as a result of specific ulceration, lupus and extensive 
burns may occasionally cause them. The voice becomes affected in 
proportion to the extent of the adhesions and the obstruction of the 
nasopharyngeal space. Occasionally perforations directly through 
either the soft cr hard palate are observed. 

Attempts to relieve by operative procedure usually end in 
failure on account of the tendency of syphilitic adhesions to recur. 

V. RETROPHARYNGEAL ABSCESS. 

This is due to an accumulation of pus in the submucous con- 
nective tissue of the posterior wall of the pharynx. 

Etiology. — As the name implies, any formation of pus, from 
whatever cause, developing in the posterior pharyngeal space would 
necessarily be considered a retropharyngeal abscess. The disease 
occurs with greater frequency in young children and the exciting 
cause, which is an invasion of the pathogenic micro-organisms into 
this space, is often difficult to discover. In a small proportion of 
cases the disease arises from caries of the cervical vertebrae and is 
either syphilitic or tuberculous. The infectious diseases of child- 
hood probably furnish the larger proportion of all cases. Ulcera- 
tions of the postpharyngeal mucosa from any cause furnish a 
pathway for infection to enter. 

Symptomatology. — The symptoms show marked variations 
between children and adults. In young children the process 
develops rather slowly and, as a rule, is not noted in the early 
stages, during which the chief symptoms are lassitude, fretfulness 
and loss of appetite. After a few days considerabie cough appears, 
with the marked changes in the character of the voice described by 
Regnier 1 as "le cri dc canard." As the disease progresses, deglutition 
becomes difficult and painful. Examination of the pharynx at this 
time will show bulging of the posterior wall largely unilateral, and 
the pus burrows in all directions, but chiefly downward. The sur- 
face becomes extremely tense and inflamed, but fluctuates under 
pressure. In adults the onset is usually more sudden, and is char- 
acterized by pain, similar to that experienced in an attack of quinsy, 
by difficult deglutition, partial loss of voice and moderate rise of 
temperature. The pain and dysphagia increase until relieved by 
rupture of the abscess or by incision. 

Diagnosis. — Inspection and palpation furnish the necessary 
information. There is bulging of the posterior pharyngeal wall 
with displacement of the soft palate and uvula and a sensation of 
fluctuation. 

Differential Diagnosis. — In young children the objective symp- 
toms of the disease somewhat resemble those of croup, which must 
be eliminated by inspection and palpation. In adults a large syphi- 
litic gumma or other form of tumor unattended by ulceration might 



3 Concours med., 1882, vol. 4, p. 578. 



694 THE PHARYNX AND FAUCES. 

be mistaken for abscess. Here also palpation serves to differen- 
tiate. 

Prognosis. — When discovered early and evacuated promptly 
the prognosis is good, but the cavity tends to refill, often requir- 
ing a second or third incision. The prognosis is less favorable in 
cases arising from caries of the cervical vertebrae. Fatalities have 
occurred from strangulation due to filling up of the larynx from 
the sudden rupture of a large abscess. 

Treatment. — The abscess cavity should be evacuated by free 
incision. In order to prevent suffocation from the flow of pus into 
the jarynx the head should be lowered and held in the lap of the 
assistant, and the operation should be performed without an anes- 
thetic, on account of the attendant dyspnea. The mouth should 
be forcibly opened with a retractor and the tongue firmly depressed. 
The pointed bistoury should be introduced as low down as possible 
upon the posterior pharyngeal wall, and a free incision carried well 
through the entire abscess wall. Following the incision, sufficient 
pressure should be made on the walls of the cavity to express all 
the retained pus, much of which will flow through the nostrils as 
well as the mouth. Immediate relief follows this procedure. For 
several days subsequently the throat should be carefully examined 
and the abscess reopened whenever pus reaccumulates. 

"Whenever the retropharyngeal abscess results from caries of 
the cervical vertebrae it should be approached externally, the abscess 
evacuated and all necrosed bone curetted away. 

As a rule, the recovery of these patients is facilitated by 
the internal administration of some form of iron or cod-liver oil, 
by nutritious diet and by a prolonged period of life in the open air. 



CHAPTER XLV. 

DISEASES OF THE OROPHARYNX. 

(Continued.) 



ACUTE INFLAMMATORY DISEASES. 

I. SIMPLE ACUTE INFLAMMATIONS. 

1. Simple Acute (Catarrhal) Pharyngitis. 

Acute catarrhal pharyngitis is an acute inflammatory process 
involving the mucous membrane of the pharynx, which gives rise 
to congestion and, in severe attacks, to infiltration of the tis- 
sues, with hypersecretion. The pharynx may be the chief seat of 
the attacks, or merely a. part of a general attack of "acute cold" 
involving the upper respiratory tract. 

Etiology. — Acute pharyngitis is dependent upon no single etio- 
logical factor, but is due to a wide variety of causes and conditions 
best described under the headings predisposing and exciting. 

Predisposing Causes. — Predisposition to the affection is based 
largely upon: 1. Lowered vitality resulting from unhealthy surround- 
ings, sedentary occupations, living in badly ventilated quarters and 
in poisonous or dust-laden atmosphere, and from excessive or 
insufficient clothing. Chronic pharyngitis predisposes to acute 
attacks. 2. Constitutional disorders, whether of digestive or assimila- 
tive nature, or with a gouty or rheumatic diathesis, occasionally the 
menstrual epoch in women. 3. Catarrhal inflammations of the nose, 
nasopharynx and larynx. 4. Excessive indulgence in stimulants, 
especially alcohol and tobacco. 5. Physical exhaustion. 

Exciting Causes. — Sudden or prolonged exposure to cold, espe- 
cially when the body is freely perspiring, is the most frequent 
exciting cause, particularly in individuals who are predisposed to 
the disease. In weakened individuals draughts of air upon the back 
of the neck or head may give rise to the affection. Inflammation 
of the adjacent structures usually accompanies this disease, and it 
commonly occurs in conjunction with acute catarrhal rhinitis or 
laryngitis. It is more prevalent during cold weather, and especially 
during prolonged periods of extreme dampness of the atmosphere. 

Symptomatology. — While the symptoms vary considerably as 
the result of the variation in the predisposing causes, the actual 
attack- is sudden, with a marked sensation of dryness and con- 
siderable pain and soreness about the pharynx, which is aggra- 
vated during phonation and deglutition. The inflammation is 
usually extensive, involving the posterior pharyngeal wall, the 
uvula, soft palate, and pillars of the fauces. These become mark- 
.edly congested, and in severe cases' the stasis is sufficient to evoke 

(695) 



696 THE PHARYNX AND FAUCES. 

edema of the uvula and soft palate. The continued inflammation 
and swelling of the posterior pharyngeal wall give rise to a sensa- 
tion similar to that of a foreign body, and the patient attempts to 
relieve the dryness by frequent swallowing. There is rarely a 
distinct chill, although chilly sensations may be complained of. 
There is some rise of temperature, varying from 99° to 103°. Pain 
is usually complained of and is more severe in patients who are 
victims of the gouty or rheumatic diathesis. In severe cases there 
is considerable difficulty in swallowing and a consequent disincli- 
nation to partake of solid food. Cough is usually present, but it is 
usually referable to the accompanying laryngitis. When edema is 
present the symptoms are sufficiently annoying to disturb sleep. 
There is but little secretion at first, but after exudation begins it 
becomes profuse, being at first serous, but gradually becoming 
mucopurulent. There is considerable interference with the timbre 
of the voice. 

Diagnosis. — Visual inspection alone cannot always be relied 
upon to differentiate between simple acute pharyngitis and the 
pharyngeal inflammations which accompany the exanthemata or 
epidemic infections like la grippe. A positive diagnosis should not 
be made until sufficient time has elapsed to make sure that one of the 
acute infectious diseases may not be the primary cause. There is 
always the possibility that the acute inflammation is the forerunner 
of a syphilitic pharyngitis. Ordinarily, however, the history, 
examination and accompanying nasal and pharyngeal inflammatory 
process are sufficient to render a diagnosis comparatively easy. 

Prognosis. — The prognosis is good, complications are rare, and 
recovery takes place in from two to ten days. 

Treatment. — In the matter of treatment each case must be a 
law unto itself, on account of the variety of causes. 

The requirements of local treatment are first that the mucous 
surfaces should be thoroughly cleansed and all tenacious mucus 
removed. This is best accomplished by means of alkaline sprays, 
which both soften and detach the secretion. This should be fol- 
lowed by an oily medicated spray like the O. B. Douglass formula 
of benzoinol (see page 496). During the acute stage no stimulating 
applications should be made to the mucous surfaces, but soothing 
remedies only are indicated. Iodin compounds, strong solutions of 
nitrate of silver, ichthyol, tannin, etc., are contraindicated during 
this stage, but as soon as the acute inflammatory process commences 
to subside, mildly stimulating applications may be employed with 
benefit. As a rule, all preparations of this kind are too severe and 
are employed in solutions too strong. Sprays are preferable to 
gargles, but direct application by means of the cotton-tipped appli- 
cator is an effective method of employing these remedies. It is 
difficult for the majority of persons, especially children, to employ 
gargles thoroughly and intelligently, inasmuch as the pharyngeal 
muscles are contracted rather than relaxed and the remedy does 
not come into contact with all the surfaces. The pain and irrita- 
tion may be considerably alleviated by the use of some soothing 



ACUTE INFLAMMATORY DISEASES. 697 

remedy in the form of tablets or lozenges, which may be allowed 
to dissolve slowly in the mouth, and which are composed of small 
quantities of menthol, camphor, and codeine. A lozenge composed 
of: — 

IJ Menthol gr. y 20 . 

01. eucalyptus m]. 

is effective in relieving pain and irritation. Among the milder 
astringent applications are the so-called Mandl's solution (see 
page 514), a 25 per cent, solution of argyrol, or a spray containing 
10 grains of tannic acid to the ounce. A useful astringent gargle 
is one composed of: — 

R Potassii chloratis gr. xxx. 

Ferri chloridi 3ij. 

Glycerini 3iv. 

Aquae q. s. ad 3iv. 

M. Sig. : One dram in water as a gargle every two hours. 

When swabbing or spraying the pharynx, the tongue should be 
well depressed and the patient instructed to utter sounds like a or 
ah, in order to expose the posterior pharyngeal wall to free view. 

Cold-water compresses or coils about the neck, especially at 
night, prove grateful to many patients, and seem to diminish the 
tendency to pain and swelling. Compresses should not be employed 
except during the early acute stage. 

Internal Treatment. — A great variety of internal medications 
have been recommended. Their employment, however, should be 
based upon the constitutional conditions which are present in the 
individual case. As a rule, a cathartic when administered at the 
commencement of the attack lessens its severity and shortens its 
duration. Experience has shown that calomel produces the best 
results. For an adult the dose should be 5 or 6 ^4-grain calomel 
tablets, administered at intervals of about one hour, preferably dur- 
ing the evening, and followed by a liberal draught of a saline early 
in the morning. In young children from 5 to 10 % -grain calomel 
tablets, according to age, should be given. If for any reason calomel 
is contraindicated, other forms of cathartics may be employed. The 
rheumatic patient should be given salol or salicylate of soda. 10 
grains, every three or four hours, until the symptoms disappear. 
These remedies may be combined with phenacetin, 5 grains every 
four hours in cases of unusual pain. Large doses of bicarbonate of 
soda, 10 to 20 grains in L. glassful of water, every two hours dur- 
ing the flay, or until the urine shows an alkaline reaction, will 
be found of great benefit. The so-called uric acid diathesis, in 
which tlie urinary secretions show an excess i if acid, is als< i benefited 
by this procedure. Bodily resistance is aided by the administration 
of quinine during the early stages. The dryness of the membranes 
of the pharynx complained of during the early stages requires the 
administration of some form of drug to stimulate the secretions. 
.Aconite, in minim doses three or four times an hour, has this effect, 



698 THE PHARYNX AXD FAUCES. 

but should be discontinued as soon as the result is obtained. The 
treatment of colds is described more fully in Chapter XXXIII. 

2. Simple Acute (Catarrhal) Tonsillitis. 

Definition. — The catarrhal form of tonsillar inflammation is 
rarely an independent disease, but is a part of a general acute inflam- 
mation of the upper respiratory tract, in which the tonsil is the 
primary seat of the onslaught. 

Etiology. — This condition is more commonly observed among 
children, probably on account of the tendency to an increase in the 
lymphoid structures at this period of life. It usually develops as a 
result of exposure to cold or dampness ; occasionally, however, it is 
due to mechanical irritation from the inhalation of irritating vapors 
or fumes. 

Symptoms, — The symptoms are similar to those observed in 
attacks of catarrhal inflammation of the upper air passages in ordi- 
nary cold in the head. The burning and painful sensation during 
deglutition is similar to that of acute pharyngitis, with additional 
stiffness and fullness about the tonsils. The mucous membrane 
covering the tonsil appears turgescent and swollen, and there is 
considerable serous exudate. In severe cases the pain radiates 
toward the ear and is often mistaken for otalgia. A rise in tem- 
perature from 100° to 103° is noted, especially in children. The 
alteration in voice and other symptoms, such as sneezing and 
coughing, result from the more general inflammatory process. 

Diagnosis. — The absence of deposits' in the tonsillar crypts, 
the superficial nature of the inflammation and its association with a 
cold are sufficient to point to its acute catarrhal character. 

Treatment. — In addition to the treatment for acute pharyngitis, 
described in the previous paragraph, the inflamed tonsil should be 
treated as follows : Painting the acutely inflamed tonsil with a 
solution of nitrate of silver, 20 to 40 grains to the ounce, often 
aborts the attack or else limits its duration. The ammoniated 
tincture of guaiac, recommended by Sajous, a teaspoonful to a 
cup of cold milk, stirred well, of which mixture a mouthful is used 
as a gargle every ten or fifteen minutes, will often shorten the 
attack. The author believes that a tonsillitis is many times the local 
manifestation of some systemic intoxication or diathesis (the uric 
acid, gouty or rheumatic) and in these conditions the appropriate 
constitutional treatment should be added to the local applications. 

II. ACUTE INFECTIOUS INFLAMMATIONS. 

The pharynx, tonsils, larynx and the glandular structures of 
the neck are subject to local infections of an inflammatory charac- 
ter, in which a systemic involvement usually accompanies the local 
condition. While there is considerable variation in the clinical 
manifestations of these affections, the etiological factors are the 
same, the variations being due to the virulence of the primary 
infection and the location of the disease. 



ACUTE INFLAMMATORY DISEASES. 699 

1. Acute Infectious Pharyngitis. 

There are two chief varieties of acute .infectious pharyngitis, 
viz. : (a) acute parenchymatous pharyngitis ; (b) acute membranous 
pharyngitis. 

(a) Acute Parenchymatous Pharyngitis. Definition. — The in- 
fectious form of pharyngitis is an acute inflammation of bacterial 
origin which invades the tissues of the pharynx. A variety of 
clinical manifestations has been described as septic pharyngitis. In 
its simplest form it is characterized by severe superficial inflam- 
mation of the pharyngeal mucosa similar to that of simple acute 
pharyngitis, but in the severe forms it attacks the submucous tissues 
and assumes the form of erysipelas, phlegmon or gangrene. It often 
occurs superficially in connection with infectious tonsillitis. 

Etiology. — Bacterial invasion through the mucous membrane 
is the exciting cause, and the streptococcus is the usual organism 
found. Among the many predisposing • causes are : grave systemic 
diseases, especially diabetes, Bright's disease, infectious fevers; 
exhaustion, chronic alcoholism, exposure to cold, traumatism, etc., 
while simple ulcerations or abrasions of the mouth or pharynx are 
contributing causes. 

Pathology. — The pathological changes depend upon the viru- 
lence of the pathogenic organism and the general condition of the 
individual at the time of invasion. In the milder cases rapid and 
intense infiltration of the tissues of the pharynx occurs. The mu- 
cous membrane becomes tense, glistening and of a dark-red hue. 
The tonsils and uvula rapidly become inflamed and edema of the 
latter is common. The general appearance of the pharynx is 
that of erysipelas. Exudation is scant in the early stages ; later, 
however, a serous exudate flows both from the pharyngeal mucosa 
and the lacunse of the tonsils. In the severe types the tissues of 
the pharynx or the uvula may become necrotic and occasionally 
gangrenous. There is a marked tendency for the disease to spread, 
either downward to the larynx or to the lymphatic glands about the 
neck. 

Symptoms. — The general svmptoms are those common to 
sepsis : remitting temperature, chills and general malaise. There 
is a sudden onslaught of intense pain in the throat. As the swell- 
ing increases, a sensation of fullness, dysphagia and voice changes 
rapidly ensue. If sloughing or gangrene is present the breath becomes 
extremely fetid, and, in grave cases, delirium and coma occur. When- 
ever the disease spreads to the glands of the neck, local symptoms — 
swelling, pain, and abscess — occur. 

There is an acute throat infection involving either the pharynx 
or tonsils, entirely due to streptococci, which is undoubtedly a 
streptococcemia and is not usually mentioned in text-books. The 
author lias observed two cases in children, eight and ten years old, 
respectively. 

Locallv, the pharynx and tonsillar region were reddened. The 
patient complained of some pain on swallowing, had headache, 



700 THE PHARYNX AND FAUCES. 

malaise, chills and a rise of one to four degrees of temperature. 
Vomiting and diarrhea persisted on and off for three days. The 
temperature was typhoid in character, remitting ; the pulse was 
weak, at times irregular, and increased with each rise in temperature. 
Prostration was pronounced. Both developed a septic endocarditis, 
which cleared up and left no permanent cardiac damage. A slight 
albuminuria persisted for eight days. Under mild antiseptic alka- 
line gargle (sodium chlorid and borate) the inflammation of the 
throat cleared up in a few days, but the general systemic condition 
yielded only after three weeks, and both made a good recovery. 

They were treated with guaiacol carbonate, 5 grains every four 
hours, and inunctions of unguentum Crede, 20 grains rubbed into 
the skin for ten minutes three times a day. The recumbent position, 
sponge baths, good nursing and restricted dietary were resorted to. 

Diagnosis. — While the disease is comparatively rare, the local 
manifestations are usually sufficient to establish a diagnosis, retro- 
pharyngeal abscess of the- region being the only affection with 
which it may be confounded. 

Prognosis. — When severe the disease places the patient's life 
in danger, and a fatal issue may result from the overwhelming 
effects of the septic poisoning on either the heart or kidneys, or 
from pharyngeal edema. 

Treatment. — At the outset free calomel purgation is essential. 
A bacteriological examination of the secretions should be made in 
order to determine the nature of the infecting organisms. Quinine 
in 5-grain doses three times daily during the first two or three days 
and large doses of perchlorid of iron, 20 to 30 minims every four 
hours, are recommended. The antistreptococcic serum has been 
recommended, and Dr. Santi reports three recoveries where he 
employed this remedy in doses of from 10 to 20 c.c. During the 
early stages some benefit may be obtained from the use of applica- 
tions or gargles containing formaldehyd. Unfortunately, formal- 
dehyd, unless largely diluted, causes pain, but is better borne about 
the throat than in either the nose or larynx. The inhalation of 
vapors of benzoin or creosote are soothing. The pain attending 
swallowing is relieved by spraying the pharynx with a 2 per cent, 
solution of cocaine ten minutes before eating. Sloughs and gan- 
grenous masses should be removed and the surfaces cleansed by 
applications of alkaline solutions or peroxid of hydrogen. Bearing 
in mind the septic nature of the affection, every effort should be 
made to conserve the patient's strength. Raw eggs, milk and strong 
broths are indicated. When swallowing becomes difficult, nutritive 
enemata may be employed. Stimulants in the form of strychnia or 
alcohol are recommended whenever the pulse becomes w r eak. The 
kidneys should be carefully guarded throughout the illness. 

(b) Acute Membranous Pharyngitis. — The etiology, pathology 
and treatment of membranous pharyngitis is similar to that of 
membranous tonsillitis and membranous laryngitis, to which the 
reader is referred; 




Fig. 456. — Carmine granules passing the epithelium of the tonsil from 
without, bacteria remaining on the surface. (Jonathan Wright, with per- 
mission.) 



ACUTE INFLAMMATORY DISEASES. 701 



2. Acute Infectious Tonsillitis. 

Comments upon the Function of the Tonsil. — Wright 1 (in sev- 
eral publications) gives his views concerning the function of the 
tonsil and asserts that we are unable to describe the function or 
physiology of the tonsil as these terms are ordinarily used, but 
rather to speak of the tonsil in its relation to the process of 
immunity and infections. His reasoning is based upon deductions 
drawn from his own experimental studies in the domain of pathol- 
ogy compared with similar phenomena in the realm of biology 
and physics. He contends that the selective action of the epithe- 
lium of the tonsil upon dust and bacteria (Fig. 456), whereby the 
latter at times is prevented from passing and at others is allowed 
to pass freely into the lymph channels, is not fully explainable from 
the laws of immunity, but rather that we are dealing with living 
matter which obeys the laws of heredity and of evolution, and that 
adaptation by natural selection is the only explanation why the 
protoplasm of the epithelial cells of the tonsillar crypts acts in the 
way it does. 

Clinically, it has long been known that infectious germs, 
especially streptococci, are commonly found in the tonsillar crypts 
of healthy individuals, and that autoinfection is probably essential 
in order to induce follicular tonsillitis. AVright believes that asso- 
ciated with the autoinvasion there is the antecedent etiological 
factor of a molecular disturbance of the sympathetic, induced by 
exposure, fatigue and various functional and systemic disorders 
and diseases ; and further that there is a wide difference in the 
surface tension, depending upon the physicochemical state of the 
fluids in which the epithelial cells are bathed. He concludes that, 
with our present knowledge, it is not accurate or proper to con- 
sider or discuss the physiology or the function of the tonsil. He 
adds the significant comment that it is a highly interesting sequence 
of events which takes place between the time the germ floats 
on food or in the air into the tonsillar crypts and the time it 
reaches the deep lymphatics which drain the tonsil. He regards it 
as a biological process of a physicochemical nature, affecting the 
surface tension of the colloids of which the cells and bacteria are 
composed. 

The Tonsils as Portals of Infectious. — Stohr and others have 
defined the peculiar arrangement of the epithelial lining of the 
tonsillar crypts wherein dehiscences exist which are believed to 
permit the entrance of micro-organisms and foreign bodies into the 
subepithelial strata. Cioodalc. Kayser, Wood and others have 
demonstrated that foreign bodies and bacteria actually do pass 
through the epithelium of the tonsil. 

Strassmann examined the tonsils from 21 cases of tuberculous 
cadavers and found tuberculous tonsils in 13. Wright and Walsham 
found no tuberculous process in a scries of removed tonsils, but 



1 Laryngoscope, May, 1909. 



702 THE PHARYNX AND FAUCES. 

this fact does not preclude the possibility that they may be avenues 
of infection. 

Primary tuberculosis of the tonsils is believed to be compara- 
tively rare. On the other hand, it is probable that in many cases 
the secondary invasion of the tonsil is never recognized, especially 
when it appears as a late manifestation. 

Williams contends that even "primary tuberculosis of the tonsil 
is less rare than is generally believed, and the failure of the faucial 
tonsils to arrest the development of the bacilli results in tuber- 
culosis of the cervical glands so commonly observed in weakly 
children." 

Concerning the "difference in the behavior of dust from that 
of bacteria in the tonsillar crypts," Wright 2 experimented with 
carmine powder dusted upon the tonsils after the manner followed 
by Goodale and others (Fig. 456) and states that "there is a striking 
differentiation in the behavior of carmine granules as distinguished 
from those of bacteria, both on the surface and in the crypts." In 
the specimen from which the illustration was made but ten minutes 
elapsed between the dusting on of the carmine and the extirpation 
of the tonsil and still the carmine had penetrated through the 
epithelium and the bacteria remained upon the surface. Further- 
more, it is apparent, as shown by Wright, that in passing the 
epithelium into the deeper spaces, the carmine granules did not 
carry any of the surface bacteria with them. "This is in direct 
accord with the idea that, at the surface exists adaptative responses 
requisite to meet those exigencies of habitual environment which 
do not exist more deeply, and that it is not so much the character 
of the tissue as its situation which counts in the function of resist- 
ance to infection, nor does so much depend upon the violence of the 
initial insult to the tissues as upon its depth." 

A different series of results followed traumatism (curetment 
of the crypts, puncture of the tonsils, etc.), for bacteria entered the 
deeper spaces to a limited extent, through the wounded surfaces. 
In this connection he (Wright) states that: "In several cases the 
patient, having an enlarged tonsil on each side, was subjected to 
the curetment of the crypts of one tonsil, leaving the other 
untouched. Sufficient force was used only to insure the removal 
of at least some of the epithelium. At the end of two days to 
one week, both tonsils were removed by the guillotine at one sitting. 
Hardened, blocked and stained in various ways, it was noticed that 
both the amount of dust and the number of bacteria were very 
largely increased within the crypts of the previously curetted 
tonsil, and, to some extent, in those of the other side there were 
more bacteria and dust than usual. The histological evidence of 
inflammation was very marked in the one and present in the other 
tonsil. Many large round cells (lvmphocytes?) were seen along 
the injured surfaces. The dust seemed to be passing in increased 
amounts, but bacteria, even at surfaces denuded of epithelium, had 



2 New York Medical Journal, January 6, 1906. 



ACUTE INFLAMMATORY DISEASES. 703 

penetrated only a very small distance. In one or two cases long, 
deep incisions were made through the substance of the tonsil. Sub- 
sequently amputated, on one of them small cocci colonies were seen 
growing at the edge of the cut surface. This was also observed 
once in the more numerous scraped tonsils. In one case small 
bacilli colonies were seen growing on the cut surface. These 
evidences of proliferation, however, were very small in extent and 
very infrequent in occurrence. In the scraped tonsils many red 
blood-cells had been effused and still existed in the tonsillar crypts. 
Often, in such a blood-clot, many bacteria would be growing, in 
marked contrast to the adjacent tissue, also suffused with blood- 
cells. In studying the stroma of inflamed tonsils I have been 
struck with the swollen condition of the endothelium of the lymph 
channels. 

In several cases one of a pair of tonsils was pierced by a sterile 
stylet of small calibre thrust in several directions. In each of these 
cases, in the pierced tonsil, small colonies of bacteria were found 
growing around solutions of continuity at a distance from the 
epithelium. This would seem to indicate that deep infection of the 
lymphoid tissue, even with surface bacteria carried in by the stylet 
or slender knife, without great disturbance of tissue and without 
much resulting inflammation, meets with less resistance to growth 
than near the surface, even when the epithelium is partially 
removed." 

Dr. Wright, in a personal communication, summarized his 
views as follows : — 

"My experiments seem to furnish conclusive evidence that 
under normal conditions bacteria do not penetrate the epithelial 
layer of the tonsil in sufficient numbers at least to set up disease. 
Yet we know from clinical experience that nerve shock from frac- 
tures, hemorrhage, nasal operations, uric acid (?), sudden cold, etc., 
produces systemic changes whereby infection is more easy and 
more dangerous. I believe that the mechanism causing surface 
infection is a chemicophysical change set up by impulses carried 
along the sympathetic nerves. This produces an alteration in the 
surface tension existing normally between the bacterial denizen of 
the tonsillar crypt and the epithelium which lines it. By virtue of 
this change the living pathogenic agent enters the system. It is 
probable that the change in surface tension does not affect the 
relation of the epithelium to dust." 

Acute infection of the tonsillar and peritonsillar tissue may be 
described under four headings, depending upon the specific locality 
involved and the clinical manifestations, viz., 1, acute lacunar 
(cryptic or follicular) ; 2, acute peritonsillitis (quinsy) ; 3, acute 
ulcerative tonsillitis, and, 4, acute membranous tonsillitis. 

Etiology. — While the clinical manifestations differ in the above- 
mentioned varieties, the same etiological factors arc more or less 
common to all. The invariable exciting cause is direct infection 
with pathogenic micro-organisms. No distincl type of organism is 
peculiar to tonsillar infections, although the streptococcus pyogenes 



704 THE PHARYNX AND FAUCES. 

is most common. The severity of the attacks and the location of 
the disease depend upon the patient's general condition, the 
virulency of the infection, and the condition of the tonsillar and 
peritonsillar tissue at the time of the attack. A predisposition to 
the disease exists in certain individuals, especially those who have 
enlarged tonsils of the chronic lacunar variety. No one, however, 
is immune. 

It is more common between the ages of four and thirty, but 
it may occur at any period of life. 'The rheumatic diathesis as 
a causative factor has been overrated. The disease sometimes 
attacks even normal tonsils. General lymphoid hyperplasia is a 
predisposing cause. Shock, overwork, anemia, mental anxiety, con- 
stitutional disease, and sojourn in vitiated or clamp atmospheres, 
sudden bodily exposure, especially of the feet, may so lower the 
vitality as to predispose the individual to this form of tonsillitic 
inflammation. 

Tonsillar infection is a common complication of grippe. It is 
more prevalent in the winter months and often occurs in epidemic 
form. This results partially from sudden atmospheric changes, but 
chiefly from the fact that the dust becomes unduly laden with 
pathogenic bacteria as a result of epidemics of grippe, scarlet fever 
and other infectious diseases. The continued presence of bacterid 
in other portions of the upper respiratory tract predisposes to ton- 
sillar infection. 

Pathology, (a) Lacunar Variety. — As a rule, this variety is 
bilateral, one tonsil becoming infected some hours before the other, 
and the pharyngeal mucosa also is inflamed. Primarily there is a 
marked engorgement of the blood-vessels of the tonsil and inflam- 
matory exudate into both the parenchyma and the crypts. This 
accounts for the tonsillar enlargement. The lacunae rapidly become 
completely filled with a septic exudate composed of epithelium, 
leucocytes and micro-organisms. These masses are yellowish in 
color and project from the lacunar openings. Occasionally the 
lacunar deposit rapidly becomes mucopurulent and overflows the 
whole surface of the tonsil, to which it gives the appearance of a 
false membrane, which is sometimes mistaken for diphtheria. After 
the lapse of twenty-four to forty-eight hours the lacunar secretion 
is dislodged. 

(b) Peritonsillitis. — In acute peritonsillitis the infection chiefly 
attacks the peritonsillar structures, in which a violent septic inflam- 
mation develops, which generally ends in abscess formation. The 
affection is usually unilateral, and the tonsil generally participates 
in the inflammatory process. As the swelling increases, the soft 
palate and uvula become swollen, congested, and often edematous 
(Fig. 455). In severe cases the swelling becomes so great as to 
interfere with both swallowing and respiration, and meanwhile it 
impedes the mobility of the lower jaw. The inflammatory process 
usually eventuates in abscess formation, and the pus collects in the 
supratonsillar tissue and gradually burrows forward and produces 
tension upon the anterior pillar and the velum (Fig. 459). Spon- 



ACUTE INFLAMMATORY DISEASES. 



705 



taneous rupture may take place at this point or through the supra- 
tonsillar fossa or the- posterior pillar. 

(c) Acute Ulcerative Tonsillitis. — Occasionally the tonsils 
become the seat of an acute ulcerative process. While the ulcera- 
tions are not deep-seated or attended with extensive parenchy- 
matous involvement, they should not be confounded with mucous 
patches or herpes. It is probable that in the majority of instances 
the ulcerative process is due to Vincent's bacillus, which attacks 
the tonsil and gives rise to ulcerations in which the peculiar fusi- 
form bacilli and the spirilla of Vincent, characteristic of this affec- 
tion, are present in the pseudomembranous exudate. The ulcers 
vary in number, they are oval and are covered with a slough. 




Fig. 457. — The exudate of Vincent's angina upon the tonsil. 
(Arrowsmith, with permission.) 

(d) Membranous Tonsillitis. — The pathological changes are 
similar to those which occur in membranous laryngitis (see 
Chapter XLVIII). 

Symptoms. — (a) Of the lacunar variety: 1. Short prodromal 
period of malaise, headache and chilliness. 2. Rise of temperature 
to from 102° to 105°. 3. Rapid pulse. 4. Usually bilateral. 5. 
Inflammation and swelling of tonsils and exudate from the mouths 
of the crypts, lasting fur from fine to four days. 6. Pain in back 
and legs. 7. Pain in tonsil, which radiates to the ear. 8. Painful 
deglutition. 9. Coated tongue. 10. Fetid breath. 11. Albuminuria 
(occasionally). Loeb 3 reports four cases and contends that acute 
nephritis is a frequent sequel of tonsillitis, and that it is frequently 
overlooked in practice by the majority of practitioners. 



.1" the American Medi 



ition, November 12, 1910. 



706 THE PHARYNX AND FAUCES. 

(b) Of the peritonsillar variety: 1. Onset sudden. Chills and 
moderate rise of temperature. 2. Usually unilateral. 3. Sharp and 
steadily increasing pain in region of tonsil. 4. Dysphagia. 5. 
Impaired mobility of the lower jaw. 6. Dribbling of saliva. 7. 
Coated tongue. 8. Inability to swallow and impeded respiration 
during later stages. 9. Rigidity of muscles of the neck. 10. Grad- 
ually increasing swelling of the peritonsillar tissues. 11. Edema of 
the uvula. 12. Abscess formation. 13. Physical exhaustion. 14. 
Otalgia. 15. Impairment of voice. 

(c) Ulcerative. — (See Vincent's angina.) 

(</) Membranous. — (See membranous pharyngitis and laryn- 
gitis.) 

(r) Vincenfs Angina: 1. Membranous exudate upon one or 
both tonsils, which is easily removed, but generally returns (Fig. 
457). 2. Erosions or ulcerations which extend to the submucous 
tissues. 3. Involvement of the submaxillary and cervical lymphatic 
glands. 4. Dryness of throat. 5. Headache, lassitude, foul breath 
and salivation. 6. The presence of the typical fusiform bacillus and 
the spirilla of Vincent. 7. Impairment of phonation. 8. Severe pain. 
9. Moderate rise of temperature. 

Diagnosis. — The diagnosis of all the forms of acute infectious 
tonsillitis is usually made without difficulty, each presenting its 
peculiar characteristics. Bacterial examination is necessary in 
Vincent's angina, also when diphtheria is suspected. Mucous 
patches and syphilitic gummata must be excluded. 

Finally, peritonsillar abscess formation must be distinguished 
from retropharyngeal abscess. The cervical glands may become 
secondarily infected. 

Prognosis. — In ordinarily healthy individuals the prognosis in 
every variety is good, the disease running its course in from three 
to fourteen days, proper treatment early instituted tending to curtail 
its duration. Fatal cases of Vincent's angina have been reported. 
A case reported by Held resulted in an attack of acute purulent 
otitis media, meningitis and death. One of the larynx and trachea 
was reported by H. W. Bruce. The patient died on the sixteenth 
day of the disease, the sloughing involving the fauces, pharynx, 
larynx and trachea. 

Complications. — Among the troublesome, and often serious 
complications the following may be mentioned: Acute purulent 
otitis media, which is always of a severe type, owing to the virulence 
of the infection ; mastoiditis, which is not uncommon ; suffocation 
from the sudden rupture of peritonsillar abscess while sleeping; 
large abscesses in the neck due to burrowing downward of the pus; 
septicemic involvement of veins and joints, and bacterial invasion of 
the submaxillary and cervical lymphatic glands. The majority of all 
cases of chronic abscess of the tonsil result from acute attacks. 
The popular theory that rheumatism is closely associated with 
infectious tonsillitis is probably based upon the fact that acute 
arthritis so often occurs intercurrently with this disease. Septic 



ACUTE INFLAMMATORY DISEASES. 707 

arthritis, endocarditis and pericarditis also occur as sequelae of 
influenza, scarlet fever, gonorrhea and other infectious diseases. 
The characteristic micro-organisms of some of these diseases have 
been found in the joints and pericardium, and these discoveries 
strongly tend to corroborate the theory advanced during recent 
years that the majority of all cases of so-called rheumatism are of 
bacterial origin and therefore septic, the infection being conveyed 
by the blood from some primary focus. 

Treatment. Prophylactic. — No one is immune and those who 
have suffered previous attacks of the lacunar or peritonsillar variety 
are especially liable to recurrence. Peritonsillar abscess is an 
annual or semiannual visitation in some individuals. Recurrence 
should lead to a careful interval examination for predisposing 
causes. Hypertrophied tonsils, especially those with lacunar 
exudate, strongly predispose to lacunar tonsillitis and peritonsillar 
abscess, and such tonsils should be removed. If chronic nasal 
accessory sinusitis exists the disease should be eradicated. Any 
serious infection about the nose or mouth should receive attention 
and all safeguards relating to the general health, especially the 
sanitary surroundings, should be employed in order to prevent a 
lowered state of vitality. 

General Treatment. — Rest in bed in a well-ventilated room of 
moderate temperature conserves the patient's resisting power, 
guards him from the development of complications, and tends to 
modify the severity of the attack. Nutritious fluid diet of milk, with 
raw eggs or Vichy, warm and concentrated beef broth or gruel, are 
well borne and easily swallowed except in cases of advanced peri- 
tonsillar abscess, when for a few days almost all food is refused. A 
brisk cathartic at the outset is of great benefit. For this purpose 
2 to 5 grains of calomel should be administered to adults, either at 
one dose or in divided doses covering four to six hours, to be 
followed several hours later by a large dose of saline. Tacobi was 
the first to extol the merits of perchlorid of iron administered 
internally as a means of controlling the severity of the infectious 
process in tonsillitis and diphtheria. For this purpose the remedy 
should be administered in doses of from 1 to 5 minims to the tea- 
spoonful of water every hour, and during the more acute stage 
every half hour. The local action of the iron upon the membranes 
is also beneficial. Quinine, the salicylates, phenacetin and aspirin 
are useful he*re as in other septic infections. Sulphate of quinine, 5 
to 10 grains twice a day, should be given during the first forty-eight 
hours. As pain increases, aspirin, in 5-grain doses three.' or four times 
a day, affords great relief and reduces the temperature. A good 
combination for the relief of pain and fever is found in a table) 
containing 2]/ 2 grains each of salol and phenacetin, with 1 grain 
of caffeine citrate, to he administered per os each hour until 
relief is obtained. The pressure pain o.f a peritonsillar abscess, 
however, is relieved only by opiates. None of these drugs need 
interfere with the regular doses of perchlorid of iron. While relief 
may he obtained by the administration of drugs, it must he remem- 



708 THE PHARYNX AND FAUCES. 

bered that in cases of peritonsillar abscess the disease steadily 
progresses to abscess formation (Fig. 459). 

Local Treatment. (a) Acute Lacunar Tonsillitis. — During 
the early stage of acute lacunar tonsillitis, applications of nitrate 
of silver in solutions of 30 to 60 grains to the ounce directly to the 
surface of the tonsil are of marked benefit, and often succeed in 
aborting the attack. The surgeon should observe the precaution 
to squeeze the surplus silver solution from the cotton swab in order 
to prevent it from dropping into the larynx, an accident which 
induces alarming laryngeal spasm 

The doses of perchlorid of iron advised for the general treat- 
ment also produce a favorable local effect upon the mucosa. The 
mucous surfaces of the tonsils should be cleansed at frequent 
intervals with the alkaline sprays heretofore advised for simple 
acute pharyngitis (see Chapter XLV). 

A.s the disease subsides and the crypts become emptied of 
secretion, mild astringent applications should be made. For this 
purpose, a solution of argyrol, 25 per cent., or ichthyol, 25 per cent., 



Fig. 45?.. — Suitable bistoury for incising peritonsillar abscesses. 

in glycerin, or Mandl's solution No. 2 (sec page 514) may be applied 
two or three times a day. 

(!>) Acute Peritonsillitis. — In a small proportion of cases peri- 
tonsillar infection resolves without the formation of abscess, this 
result being secured either in response to the general and local 
measures heretofore outlined or, more probably, for the reason that 
the infection is mild in type. All others develop abscess (Fig. 459). 
Xo relief is obtained from the severe suffering until the abscess is 
evacuated, either spontaneously or by incision. The local treat- 
ment advised for the lacunar type during the early stages is appli- 
cable in peritonsillitis. Gargling, however, soon becomes extremely 
painful and should be abandoned. Cracked ice slowly dissolved in 
the mouth, or steam inhalations medicated with compound tincture 
of benzoin, 1 dram to a pint of boiling water, are soothing. Consid- 
erable relief from the painful deglutition is afforded by painting the 
tonsils and pharynx with a 5 per cent, solution of cocaine about ten 
minutes previous to eating or drinking. Hovell has ingeniously 
suggested that the pain of swallowing is lessened by placing the 
hands over the ears and pushing the auricle upward during each 
attempt at swallowing. 

As soon as the character of the swelling indicates the formation 
of abscess, relief should be obtained by means of incision into the 
cavity, a procedure which often saves many weary hours of suffer- 
ing, and at the same time prevents such complications as the bur- 
rowing of the pus and the extension of the infection to the sur- 
rounding parts. Preliminary scarification of the tissues for the 



ACUTE INFLAMMATORY DISEASES. 



709 



purpose of local bloodletting is of no avail, and the fresh cuts add 
fuel to the flame of the burning, lancinating pain. The operation 
should be preceded by thorough cleansing of the oral cavity and 
an application of a 10 per cent, solution of cocaine to the point to 
be incised. The cocaine should be applied in such a manner as to 
prevent the swallowing of the drug. A long-handled bistoury with 
a short cutting surface (Fig. 458) is convenient for the operation. 
The blade should be wound with damp cotton to within 1 inch of 
the point. The mouth should be opened as widely as possible, and 
the tongue depressed. With bright illumination the knife is then 
introduced at the most prominent point of the abscess, which is 
generally about on a level with the base of the uvula, and about 




Fig. 459. — The general appearance of a peritonsillar abscess, and the 
line of incision for its evacuation. 



midway between the uvula base and the upper wisdom tooth of 
the affected side. The incision should be carried from above 
downward (Fig. 459), but many operators advise that it should 
be carried horizontally, and from without inward toward the uvula. 
If the cavity is thus reached a free gush of pus will follow the 
withdrawal of the knife. Failing to reach the pus sac with the 
knife, a stiff, blunt probe carried through the incision with consider- 
able pressure will often enter the cavity, which may then be 
enlarged by introducing a pair of slender artery clamps, to be 
widely opened upon withdrawal. Some laryngologists operate upon 
these abscesses by plunging a closed forceps, like Lister's sinus 
forceps, through the wall directly into the cavity, and opening the 
blades vertically before withdrawal. The procedure, although 
attended by undue pain, obviates the danger of wounding blood- 
vessels. The ascending pharyngeal artery is the vessel most likely 
to be injured during the incision. The pus is usually offensive. 



710 THE PHARYNX AND FAUCES. 

After-treatment. — The cavity should be thoroughly syringed 
either with a normal salt or boric acid solution, and then gently 
curetted with a small ring curd. Recovery is rapid and recurrence 
unusual, although multiple abscesses sometimes occur. Whenever 
the pus has burrowed its way downward along the lateral pharyn- 
geal wall it may become necessary to incise through the posterior 
pillar or even lower down. Obviously the incision never should be 
through the tonsil. 

Bilateral peritonsillitis is not uncommon, but fortunately one 
abscess is usually well on toward recovery before the other develops. 
Convalescence is hastened by tonics, free diet and change of air. 

(c) Ulcerating. — Cleanse the surface of the ulcer before making 
applications. In case the ulcer is covered with a slough, the latter 
may be removed by rubbing with dilute peroxid of hydrogen or by 
the curet. After cleansing, the ulcer should be painted with nitrate 




Fig. 460. — Extensive involvement of the pharyngeal walls with Vincent's 
angina. (Afrowsmith, with permission.) 

of silver solution, 10 to 60 grains to the ounce, or argyrol solution, 
25 per cent. 

(</) Membranous Tonsillitis. — (See Membranous Laryngitis.) 

(c) Vincent's Angina. — This disease is usually contagious and 
has neither geographical nor time limitations. There is no known 
specific. While the tonsil seems to be the favored site for its 
development, it may extend to the walls of the pharynx, the larynx 
(Fig. 460) and the buccal cavity. Bayer reported a case that lasted 
four months, upon which local measures of the most radical char- 
acter, including curetment and the galvanocautery, produced no 
effect. Vincent recommends applications of iodin to the ulcerated 
surfaces. Others have advocated chlorate of potash in saturated 
solutions as an application to the ulcers. The dry powder may be 
rubbed in. 

Arrowsmith has reported three cases, in one of which the 
disease extended over the soft palate and epiglottis (Fig. 461), and 
in another the submaxillary glands became intensely swollen. 

His treatment consisted of cleansing the ulcers with enzymol 
followed by a boric acid wash and a final application of a 10 per 
cent, solution of trichloracetic acid, the latter being gratefully 
borne and at the same time effective in terminating the disease. 



ACUTE INFLAMMATORY DISEASES. 



711 



Richardson treated fifteen cases successfully by "curetting out the 
slough, cleansing with antiseptic solutions and daily applications of 5 
per cent, solution of nitrate of silver." 

In the author's experience thorough scraping of the ulcerated 




Fig. 461. — The exudate of Vincent's angina has extended over the 
tonsil, velum, and a portion of the buccal cavities. (.Irroivsmith, with 
permission.) 

surface, followed by an application of tincture of iodine, well rubbed 
in, lias produced the best results. Salvarsan has also been employed 
with beneficial results. 



III. TRAUMATIC PHARYNGITIS. 

Etiology.— The exposed location of the pharynx, especially its 
posterior wall, renders it peculiarly liable to injury from inhalation of 
steam, flame or superbeated air, scalding from the ingestion of hot 



712 THE PHARYNX AND FAUCES. 

fluids or foods, from excoriation by corrosive poisons, and from in- 
juries resulting from stab wounds, pencils, pipestems, splinters, broken 
glass, fishbones, and other foreign bodies. It is also liable to become 
injured from swallowing rough or hard substances. 

Pathology. — When caused by flame, escharotics, scalds or othef 
burns, rapid infiltration of the pharyngeal mucosa takes place, the 
membrane at first assuming a dark-red color. Edema when present 
extends to the glottis and intralaryngeal spaces. The mucous surfaces 
later on assume a grayish color, with a tendency to erosion and super- 
ficial sloughing. In severe cases phlegmonous-like ulcers result- 
Ordinary wounds of the pharynx, providing no infection takes place, 
heal rapidly and leave no permanent injury. If foreign bodies become 
impacted in the soft tissues, deep-seated inflammation, ulceration and 
suppuration may ensue. Retropharyngeal abscesses occasionally occur 
in this manner. 

Symptoms. — The marked symptoms are severe pain and sore- 
ness in the pharynx, but these are usually overbalanced by the dys- 
phagia and often alarming dyspnea referable to the accompanying 
esophageal and laryngeal inflammation. Healing is usually rapid un- 
less the abrasions become infected, in, which event the symptoms are 
similar to those of peritonsillar and retropharyngeal abscess. 

Treatment. — Foreign bodies should be located by means of the 
probe or X-ray and removed. The suturing of deep wounds facilitates 
healing. Superficial burns or scalds require soothing applications. It 
is often necessary to spray the surfaces with a solution of cocaine, or 
apply orthoform in order to control the pain. Cleansing sprays or 
gargles are required to keep the surfaces clean and free from secre- 
tions. Inhalation of steam, medicated with compound tincture of ben- 
zoinol, 1 dram to the pint, relieves the tension and pain. If sloughing, 
ulceration or gangrene ensue, it then becomes necessary to remove the 
sloughing tissue by means of the curet or scissors. When corrosive 
poisons have been taken, proper antidotes are to be employed, provid- 
ing too much time has not elapsed. Wlien carbolic acid has been 
swallowed its caustic effects may be prevented by gargling and swal- 
lowing pure alcohol, providing it can be applied within ten minutes. 

Alarming dyspnea indicates pharyngeal or laryngeal edema (Fig. 
4%), and rapid tracheotomy may become imperative. Traumatic ab- 
scesses should be promptly incised under strict asepsis. When severe 
ulceration intervenes, the period of convalescence is slow, often requir- 
ing watchful care during several months to prevent adhesions and 
deformities. 

IV. TOXIC PHARYNGITIS. 

The internal administration of drugs may induce inflammation 
of the mucous membranes of the pharynx and mouth. Certain in- 
dividuals seem to possess idiosyncrasies in this respect, and, in these, 
the toxic symptoms are liable to develop from even small doses. Mer- 
cury, iodid of potash, arsenic, lead, antimony, copper, zinc, and bella- 
donna are the chief drugs in this category. Mercury absorbed as a 
medicinal agent, or in occupations where quicksilver is used, a peculiar- 



ACUTE INFLAMMATORY DISEASES. 713 

form of inflammation, involving the pharynx, mouth, tongue and 
gums. Calomel, even in small doses, has been known to produce this 
toxic effect. Salivation and superficial ulceration, with dysphagia, are 
the chief symptoms. The tongue is coated and the breath foul. 

Treatment. — Cessation from contact with the drug and the inter- 
nal administration of iodid of potash or chlorid of potassium are indi- 
cated, the mouth and throat meantime being frequently cleansed with 
dilute peroxid of hydrogen. Iodid of potash, when administered in 
large doses, causes marked redness and often, inflammation of the 
mucosa, a symptom which indicates the necessity for reduction of the 
dose for a few days. A dose of sulphate of magnesia will relieve the 
congestion. 

The use of drugs like belladonna, iodid of potash, etc., should be 
suspended as soon as their physiological symptoms appear. 



CHAPTER XLVI. 

DISEASES OF THE OROPHARYNX. 
(Continued.) 



CHRONIC INFLAMMATORY DISEASES. 

I. CHRONIC HYPERPLASTIC PHARYNGITIS. 

In this disease the inflammatory process varies from a chronic 
inflammation of the entire mucosa with swelling of the tissues to 
a hyperplasia which involves the glandular structures of the mem- 
brane, these variations depending- upon the severity or chronicity 
of the disease, or upon the particular tissues involved. For con- 
venience of description two general subdivisions are made: (a) 
simple chronic pharyngitis; (b) granular pharyngitis. 

Simple Chronic (Hyperplastic) Pharyngitis. 

This is a chronic inflammation of the pharyngeal mucosa 
resulting in hyperplasia. When associated with impairment of the 
elasticity of the pharyngeal tissues, the affection is termed "relaxed 
throat.'' 

Etiology. — The causative factors include: 1. Frequent attacks 
of acute pharyngeal inflammation. 2. Errors in digestion and 
assimilation, notably in gout}- and rheumatic subjects, especially 
when accompanied by asthma, chronic bronchitis, cardiac or kidney 
disease. In this class the clinical appearance and symptoms are 
always exaggerated. 3. Debility, anemia and plethora. 4. Climate, 
hygiene and surroundings are often responsible for the affection, 
as may be observed in those who reside in a damp or changeable 
atmosphere, or who work or sleep in overcrowded or badly venti- 
lated rooms, or who neglect needed intranasal hygiene. 5. Intra- 
nasal diseases. Obstructive lesions in the nose, whether inducing 
postnasal secretion or mouth-breathing, and chronic accessory sinus- 
itis are common etiological factors. Of the latter the posterior 
ethmoidal cells and sphenoidal sinuses more commonly induce 
chronic pharyngitis because their secretions flow backward into 
the pharynx and give rise to hawking. 6. Misuse of the voice, 
whether from strain, undue or faulty production (commonly 
observed in public speakers, singers, hucksters, etc.). 7. Local 
irritants, like dust and fumes from stone-cutting, tobacco factories 
and chemicals of various kinds, or the excessive indulgence in 
alcohol and tobacco, tend to cause chronic hyperplastic pharyn- 
gitis. The latter act both as local irritants and by dilating the 
blood-vessels. 
(714) 



CHRONIC INFLAMMATORY DISEASES. 715 

Pathology. — In the early stages the membranes usually become 
symmetrically hypertrophied, and of a dull red hue due to the 
inflammatory exudate into the submucous tissues. As the disease 
progresses there appears upon the posterior wall a network of 
blood-vessels. At the same time small lymphoid nodules may 
appear upon the posterior pharyngeal wall. The secretions are 
altered and the surface may be covered with a film of tenacious 
mucus. 

Symptoms. — The chief symptoms are dryness and soreness of 
the pharynx, which are more noticeable in the morning. The secre- 
tions gradually become less fluid and less in quantity. To dislodge 
the tenacious secretion requires almost constant hawking efforts on 
the part of the patient. There is some loss of vocal resonance, and 
the throat tires easily. Singers feel this more keenly. Frequently 
there is a sensation of a foreign body in the throat. Relaxation of 
the uvula, when sufficient to cause a tickling sensation at the base 
of the tongue, gives rise to an irritating cough. 

General Treatment. — The preliminary examination should be 
exhaustive and should include the intranasal region, digestive 
system, and a careful search for any organic disease or diathesis, 
especially gout and rheumatism. The habits, especially those 
relating to hygiene, alcohol, tobacco and narcotics, should be inves- 
tigated. Plethoric individuals, if possible, should sojourn at some 
watering-place where cathartic and pure spring waters may be 
employed, and the diet regulated according to the patient's needs. 
Anemic persons are greatly benefited by life in the open air, tonics, 
full diet, the administration of iron and strychnia, while such seda- 
tives as valerianate of zinc and the bromids afford added relief in 
neurotic patients. Pure spring water, taken in liberal quantities 
between meals, is beneficial. Overuse or misuse of the voice 
requires rest of the vocal organs, to be followed by proper voice 
training - . It is important to adopt all reasonable measures to 
prevent colds. These measures have been described in Chapter 
XXXIII. In young children the disease may be prevented by the 
removal of diseased adenoids and tonsils. 

Local Treatment. — A thorough daily cleansing of the mucosa 
of the nasopharyngeal tract with bland, alkaline, non-irritating solu- 
tions, such as normal salt solution or biborate of soda, preferably 
by means of coarse sprays, is of much benefit. The spraying should 
be partly through the nostrils, with the head held well backward. 
This effectually softens and removes the retained secretion. In 
large cities wherein the inhabitants are unduly exposed to dust 
and other irritants, the daily cleansing of the pharynx and nasal 
cavities with bland solutions is a most beneficial measure. Gargles 
may be substituted for sprays in patients who are trained in their 
use. Solutions containing glycerin or strong alkalines are irritant 
and should he avoided, inasmuch as they lend to drain the tis- 
sues of needed fluids. Astringents are sometimes useful for the 
purpose of reducing the local inflammation. Applications of 
Mandl solution No. 1 (see page 514), argyrol, 25 per cent., nitrate 



716 THE PHARYNX AND FAUCES. 

of silver, 20 grains to the ounce, or ichthyol, 25 per cent., may be 
applied to the surface daily. Medicated oily sprays, preferably 
the Douglass formula of benzoinol (see page 496) applied two or 
three times a day or in the night, if necessary, for the relief of the 
cough, are soothing and allay irritation. The oil spray should 
follow the preliminary cleansing. 

Chronic Granular Pharyngitis. 

Synonyms. — Clergymen's sore throat ; chronic follicular pharyn- 
gitis ; chronic hypertrophic pharyngitis ; pharyngitis hyperplastics 
lateralis. 

The majority of authors describe this form of pharyngeal 
inflammation under several headings, but in the opinion of the 
author the variations in the clinical manifestations relate to dif- 
ferences in habits, occupation and diathesis. For instance, the 
granular or follicular variety is more common among those who 
habitually use the voice to excess, or who have previously shown 
a tendency to lymphoid hyperplasia; individuals who habitually 
use alcohol and tobacco to excess, or who possess a tendency to 
gout, rheumatism or allied diseases, furnish a larger proportion 
of the general hyperplastic type. Anemic persons or those whose 
occupations expose them to vitiated air, dust, fumes, etc., are more 
likely to develop the pimple inflammatory form with but little 
hyperplasia or other tissue changes. 

Etiology. — The disease results chiefly from frequent attacks 
of acute pharyngeal inflammation. Long-continued, improper, or 
excessive use of the voice, especially in outdoor speaking to large 
audiences or in badly ventilated theatres or public buildings, inter- 
feres both with muscular control and with the circulation of the 
pharyngeal tissues. The result is stasis, which is followed by con- 
gestion and inflammation. The nutrition of the parts is thus inter- 
fered with, and if persisted in the follicles finally become diseased 
and enlarged and the mucous membrane of the posterior pharyn- 
geal wall more or less granular. These symptoms are aggravated 
by constitutional conditions, particularly digestive disturbances, 
and affections of the heart, liver, kidneys and lungs. Rheumatism 
and gout or overindulgence in stimulants and narcotics add to the 
severity of the affection. Obstructed nasal respiration, undue 
exposure to dust, the irritation of gases or from vitiated air are 
also contributive causes. 

Pathology. — -The pathological alterations in the mucous mem- 
brane and submucosa vary. In the severer forms there is at first 
an increase in the connective-tissue elements, with corresponding 
thickening. The long-continued intumescence irritates the glan- 
dular structures of the mucosa and true lymphoid enlargement 
results. The granular masses appear upon the posterior pharyn- 
geal wall and vary in size from a millet seed to a bean. Usually 
but one or two are present, but occasionallv the posterior wall is 
thickly dotted with small glands and with dilated veins, which 



CHRONIC INFLAMMATORY DISEASES. 



717 



radiate over the intervening spaces (Fig. 462). Occasionally the 
lymphoid masses are observed only along the lateral wall (pharyn- 
gitis hyperplastica lateralis), parallel with the posterior pillar and 
extending into the nasopharynx. 

Symptomatology. — The chief symptoms are a sensation of 
tickling in the throat, cough, alterations in the voice, and partial 
loss of control of the muscles of phonation. The burning, tickling 
sensation in the pharynx is persistent ; it is much worse upon lying 
down, and is relieved temporarily by hawking or by coughing. The 
efforts to relieve the tickling sensation and to clear the throat of 
the accumulation of thickened mucus not only produce hoarseness 
or loss of voice, but irritate the inflamed pharyngeal mucosa. 




Fig. 462. — The glandular enlargement and dilated veins which accompany 
chronic granular pharyngitis. 



Singers under these circumstances complain of throat tire, loss 
of flexibility and difficulty in placing tones. This state is fre- 
quently accompanied by nerve exhaustion and great depression. 
Deglutition is rarely painful. Laryngitis in varying degrees usually 
accompanies the affection. 

Diagnosis. — The diagnosis is never difficult. The history of 
the case furnishes important data, while the examination reveals 
inflammation and thickening of the mucosa, upon the surface of 
which glandular nodules are scattered. 

Prognosis. — If the original cause of the difficulty can be deter- 
mined and remedied and the hypertrophied masses removed, a 
favorable prognosis may be rendered. 

Treatment. — The instigation of local treatmenl should be ante- 
dated by a thorough examination of the nose and nasopharynx 
and a careful study of the general health of the patient. All intra- 
nasal deformities and diseases should be remedied and such opera- 



718 THE PHARYNX AND FAUCES. 

tive procedures instituted as the case demands. Attention should 
be given to any constitutional disorders which may be present. 
Whenever alcohol or tobacco are used to excess they should be 
interdicted. For those cases which have resulted from improper 
use of the voice intelligent vocal training should be sought. Acute 
exacerbations are greatly relieved by cathartics. Moderate doses 
df calomel or cascara are favored for this purpose. Locally the 
destruction of diseased follicles is an important measure. For this 
purpose the galvanocautery electrode heated bright red is effective. 
When large blood-vessels radiate across the posterior pharyngeal 
wall it is sometimes necessary to destroy them by means of the 
galvanocautery puncture. It is unwise to destroy large numbers of 
follicles at a single sitting on account of the troublesome reaction 
which follows. The granular masses may be clipped off with a 
tonsil punch (Fig. 477). Curetment of the entire posterior pharyn- 
geal wall, including the enlarged glands, is effective. For this 
purpose Mayer's pharyngeal curet (Fig. 463) is a convenient instru- 
ment, and there is less reaction than from the galvanocautery. The 
surfaces should be thoroughly cocainized previous to operative 
attempts of any kind. During the interval between these operations 



t- 



Fig. 463. — Mayer's pharyngeal curet. 

the pharyngeal wall should be kept clean by gargling or spraying 
with normal salt or other alkaline solution. Excessive lateral 
hyperplasias may also be removed by means of the cutting punch 
forceps, care being exercised to avoid wounding the posterior pil- 
lars. Parker suggests that by introducing the point cold into the 
space between the glands and the pillar, and forcing the mass 
toward the median line before turning on the current, then burning 
through laterally, the posterior pillar may be avoided. 

These operations are followed by considerable pain and sore- 
ness, which last from twenty-four to forty-eight hours, during 
which the patient should be directed not to use the voice, and for 
the relief of pain and soreness plain hot-water gargles and applica- 
tions of orthoform should be employed. If swallowing is unduly 
painful the pharynx may be painted twenty minutes before meals 
with a 4 per cent, solution of cocaine. 

After the operative procedures have been completed and the 
wounded surfaces healed, marked benefit is obtained from the daily 
local application of mild astringent preparations. Mandl's solu- 
tion No. 2 (see page 514), solutions of nitrate of silver, gr. 10 to 
30 to the ounce, and argyrol, 2? per cent., are useful astringents. 
Adults and older children may lie taught to apply these remedies 
to their throats. The internal administration of appropriate reme- 
dies is of service in patients whose pharyngeal symptoms are 
aggravated by constitutional disorders. The reader is referred to 
Chapter XXXIII for a description of useful preventive measures. 



CHRONIC INFLAMMATORY DISEASES. 719 

II. CHRONIC ATROPHIC PHARYNGITIS. 

Definition. — Chronic atrophic ^pharyngitis is due to a chronic 
inflammatory process which results in contraction of the mucosa 
and obliteration of many ^of the secreting glands and blood-vessels, 
with consequent atrophy. 

The disease occurs in two distinct forms, which are termed 
simple atrophic pharyngitis and fetid pharyngitis. 

Simple Atrophic Pharyngitis. 

Synonyms. — Dry pharyngitis ; pharyngitis sicca. 

Etiology. — As a rule, this disease occurs in conjunction with 
atrophic rhinitis and arises from the same causes. Primary atrophic 
pharyngitis is rarely observed. Nasal obstruction and empyema 
of the accessory sinuses, with or without such local irritants as the 
inhalation of irritating fumes and bad hygiene, is the primary cause 
in the larger proportion of cases ; all others result from digestive 
disorders or from grave constitutional affections, such as diabetes 
or cirrhosis of the liver and kidneys. 

Pathology. — The chief pathological changes in the mucosa are 
the gradual obliteration of the glands and to a less degree the 
destruction of blood-vessels. This interferes with the nutrition of 
the parts and alters the character of the secretions. There is a 
marked diminution in the quantity secreted, with a tendency to 
become thick and tenacious. In severe cases the secretion becomes 
inspissated and adheres closely to the surfaces of the mucosa. 

Symptomatology. — The chief symptom is a disagreeable sen- 
sation of dryness in the back of the throat, accompanied by more 
or less burning or itching. These symptoms often become almost 
intolerable, requiring strenuous hawking in order to remove the 
thickened secretion. The large collections of secretion produce 
changes in the voice, and hoarseness is common. The color of 
the secretion varies from light yellow to brown or even grayish 
or greenish crusts. The general appearance of the membrane is 
thin, and the breath is affected by the odor from the retained 
secretion. 

Diagnosis. — The disease is based upon the history of the 
case and the symptoms above described. 

Prognosis. — The prognosis depends largely upon the stage of 
the disease. The pathological changes in the mucosa are permanenl 
and unalterable, but great relief is obtained from arrest of the 
process and local treatment. 

Treatment. — Whenever the disease is caused by intranasal 
obstruction or empyema of the accessory sinuses, these diseased 
conditions and deformities should be thoroughly eradicated by 
operation. Any associated constitutional disorders should receive 
appropriate treatment and proper hygienic surroundings should be 
maintained. Aside from this the general treatmenl outlined for 
chronic atrophic rhinitis (see Chapter XXXIV) and simple chronic 
pharyngitis (above described 1 should be employed. 



720 THE PHARYNX AND FAUCES. 

Fetid (Atrophic) Pharyngitis. 

Etiology. — The fetid variety differs from the simple in the 
character of the secretion, which is thick, tenacious, and extremely 
offensive. It invariably accompanies fetid rhinitis and has the same 
etiological factors and pathology. It occurs in the young — more 
often in girls than in boys — and is always accompanied by anemia. 

Symptoms. — The symptoms are similar to those of simple 
atrophic pharyngitis with the addition of fetor and a greater tend- 
ency of the secretions to adhere to the posterior wall of the pharynx. 

Treatment. — The measures recommended for the simple variety 
are applicable here. The removal of the crusts requires daily treat- 
ment by the physician until the patient becomes expert in removing 
them, and in the application of proper local remedies. For a 
description of the general and local measures of treatment the 
reader is referred to the treatment of fetid rhinitis (Chapter 
XXXIV). 

III. CHRONIC TONSILLITIS.' 

(a) Chronic hyperplastic tonsillitis. 

(b) Chronic lacunar tonsillitis. 

(c) Lingual tonsil hyperplasia. 

There are two general varieties of chronic inflammation of 
the faucial tonsils, viz., the hyperplastic and the lacunar. The 
lingual tonsil also is subject to chronic hyperplasia. 

Chronic Hyperplastic Tonsillitis. 

Synonyms. — Chronic hypertrophic tonsillitis ; hypertrophied 
tonsils. 

This is a chronic inflammation of the parenchyma of the tonsil 
resulting in hyperplasia. In young children the tissue increase is 
largely lymphoid, while in adult life there is a continual increase 
in the connective-tissue stroma. 

Etiology. — It is essentially a disease of childhood, but may 
continue to adult life. It rarely commences in adult life except as 
a result of syphilis or some other specific infection. The affection 
usually is associated with adenoids, and the etiological factors are 
similar to those which induce hyperplasia of the lymph-glands of 
the nasopharynx. The usual exciting causes are the acute exan- 
themata and other acute fevers, grippe, etc., frequent colds and 
long-continued inflammations of the upper respiratory tract. There 
is a hereditary tendency in many families which predisposes to 
lymphoid hyperplasia. 

Pathology. — There is a marked increase in the lymphoid tissue 
and a gradual accumulation of new connective-tissue deposit in the 
tonsillar stroma. When the connective tissue predominates the 



1 The reader is referred to Chapter XLV for general remarks upon 
the function of the tonsil and the tonsils as portals of infection. 



CHRONIC INFLAMMATORY DISEASES. 721 

tonsil becomes fibrous and therefore harder than when lymphoid 
tissue is in excess. The tonsillar hyperplasia sometimes reaches 
enormous proportions, causing them to project across the pharyn- 
geal space, where they lie in contact when the throat is in repose. 
The shape is generally ovoid (Fig. 476), with marked variations. 
The enlarged tonsil may chiefly project toward the median line, 
or an ear-like enlargement may drop downward into' the glosso- 
epiglottic fossa. In other cases the enlargement is chiefly in an 
upward direction and fills the supratonsillar fossa, or the rounded 
tonsil may lie buried beneath the faucial pillars, which are adherent 
to its surface. The surface in general is smooth, but is usually 
honeycombed by the lacunar openings. More or less inflammation 
of the pharyngeal mucosa accompanies this affection. 

Symptoms. — The symptoms are so closely allied to those pro- 
duced by adenoids (see Chapter XLIII) that it is difficult to dif- 
ferentiate one from the other, and in most cases both affections 
are present. The chief symptom is interference with respiration. 
Mouth-breathing, restless sleep with snoring and nightmare, open 
mouth with a dull, expressionless countenance, aprosexia, etc., are 
more particularly the result of adenoids, but difficulty in swallowing 
and obstructed and imperfect phonation and respiration may be of 
tonsillar origin. Children with enlarged tonsils are especially liable 
to colds, which are characterized by acute inflammation of the 
pharynx and tonsils. During these attacks the patient becomes 
more restless at night and the persistent hacking cough prevents 
continuous sleep. The cervical glands are frequently enlarged. 
With each acute exacerbation, especially when infectious, there is a 
marked tendency to attacks of middle-ear suppuration. Enlarged 
tonsils predispose to attacks of acute lacunar tonsillitis, scarlet 
fever and diphtheria. Pain and discomfort are induced by the 
traction which occurs upon the inflammatory adhesions which unite 
the body of the tonsil and the faucial pillars. As adolescence 
approaches, the tonsils become more fibrous and contraction may 
take place and reduce the lymphoid tissue, with a corresponding de- 
crease in the size of the tonsil. This termination is by no means the 
invariable rule, inasmuch as the enlargement in many cases persists 
through life. 

Diagnosis. — The diagnosis is never difficult and is based upon 
an examination of the oropharynx, combined with digital manipula- 
tion. It is sometimes necessary to differentiate benign or malig- 
nant tumors of the tonsil. 

Prognosis. — With proper treatment the prognosis is good. 

Treatment. — During the examination the size, shape and 
density of the tonsils should be noted, and I he crypts probed in 
order to determine whether they contain pus or other degenerative 
material. A curved probe, passed between the Faucial pillars and 
the tonsils, will reveal adhesions when present, and no examination 
should l>e considered complete until the pharyngeal vault has been 
explored for adenoids and the base of the tongue examined For 
lingual tonsil hypertrophy. The treatment uf the hyperplastic 



722 THE PHARYNX AND FAUCES. 

tonsil is essentially surgical except in cases of slight enlargement when 
uncomplicated by lacunar secretion. Local applications have but little 
effect in reducing the hypertrophy. 

Indications for Removal. — When associated with adenoids, 
which require removal, the tonsil, even moderately enlarged, should 
be removed at the same time. The necessity for the removal of the 
diseased tonsil is not to be measured by its size. Any visible enlarge- 
ment is an indication of disease. We have heretofore stated (Chapter 
XLV1 ) that there is strong presumptive evidence that the tonsil crypts 
not only harbor micro-organisms, but furnish a pathway for the 
entrance of bacteria into the deeper tissues. The chief indications are : — 

1. Recurrent attacks of acute tonsillitis. 2. Faucial obstruction. 
3. Otalgia, otorrhea and deafness. 4. Impairment of voice and speech. 
5. Systemic infection. 6. Anemia, cough, bronchial affections and 
arrest of physical development. 7. Enlarged cervical glands. 

In singers with enlarged tonsils who have already learned their art 
there is some danger that the operation may alter the action of the 
pharyngeal muscles and thus, temporarily at least, impair the quality 
of the voice. This never has happened in the author's experience, for 
in all cases the voice has improved, both in quality and resonance. In 
order to avoid such complications pupils should undergo a thorough 
examination by a competent rhinologist before commencing the vocal 
training, and submit to such operations as may be required to render 
the upper respiratory tract healthy and free from abnormalities. 

During recent years the medical profession, and to a Targe extent, 
the laity, have come to regard the tonsil as the chief portal of entry of 
various systemic infections. Especially has there arisen a growing de- 
mand for the removal, of tonsils in adults. Internists as a rule refer 
these patients for operation. This is recommended for the relief -of 
rheumatism and other systemic infections in the belief that the focal 
point is located in the tonsil. It is not uncommon for laymen to re- 
quest that the tonsils be removed. It is a fact that chronic abscesses 
and other foci are often present in and around the tonsil, making 
necessary their removal, and with entire relief of the secondary infec- 
tions, but the author here ventures a word of caution against the in- 
discriminate removal of the tonsil in adult persons in cases where no 
positive evidence of infection exists. All other possible causes should 
be eliminated before resorting to any operative procedure upon the 
tonsil. Among these may be mentioned chronic middle ear suppura- 
tion, nasal accessory sinusitis, the teeth, gall bladder, appendicitis and 
seminal vesicles. 

Methods of Removal.— The various operative procedures which 
have been devised for removing the tonsils may be classified under 
three general headings: — 

1. Complete removal (tonsillectomy), including the capsule. 2. 
Complete removal (tonsillectomy) without removing the capsule. 3. 
Partial removal (tonsillotomy). 

There are numerous variations in the technique, and numerous 
instruments have been devised for the various operative procedures. 



CHRONIC INFLAMMATORY DISEASES. 



723 




Complete Removal {Tonsillectomy) , Including the Capsule. — This 
operation may justly be termed the radical tonsil operation. Regard- 
ing the merits of complete eradication, the vast majority of American 
rhinologists favor the procedure for the reason that, unless the entire 
tonsil is removed, full benefit of the operation is not secured. It is 
known that, if the base of the tonsil is left intact, acute infections, 
peritonsillar abscess and even recurrence of 
hyperplasia are likely to occur. The credit for 
placing the tonsil operation upon a rational and 
scientific basis by insisting upon the complete 
removal of the diseased tissue is due to Ameri- 
can rhinologists, and in the author's opinion 
there no longer exists any doubt as to the. 
merits of these more radical, but at the same 
time more reasonable, procedures. There is 
by no means unanimity of opinion regarding 
the removal of the tonsillar capsule, but the 
majority of those who favor the complete oper- 
ation remove both the tonsil and the capsule. 

not favor removing the capsule, and contend that its removal is un- 
necessary and more liable to be followed by wound infection. It is 
true that the reaction is more severe and prolonged when the capsule 
is removed, but the published reports have not as yet shown serious 
complications or sequela?. 

There are two arguments which favor the removal of the capsule: 
1, it insures the total ablation of the tonsil; 2, the operative technique 
is greatly facilitated thereby. 



Fig. 464. — Points 
for injecting cocaine 
to induce local anes- 
thesia of the tonsil. 

Myles and others do 





Fig. 465. — Thomson's tongue depressor, to he held by an 
assistant during the tonsil operation. 



Operations upon the tonsil should be performed in 
a hospital if possible, especially when performed upon 
young children and under general anesthesia. It is even 
safer for adults upon whom the operation is performed 
under local anesthesia to remain in the hospital For 
twenty-four hours. 

The complete operation upon the tonsil should not be 
considered a simple or mere minor operative procedure unattended by 
danger. Unfortunately, the older operation of partial removal or 
"clipping" has created in the minds of the laity a general impres- 
sion that the tonsil operation is insignificant, and may be safely 
performed at any time or in any place. 



724 



THE PHARYNX AND FAUCES. 



The reasons which favor the hospital as a place for this opera- 
tion are real and tangible : — 

1. Asepsis is more easily maintained. 

2. A well-equipped operating- room inspires the confidence of 
the surgeon and thereby favors his technique. 

3. The facilities of the operating room are helpful in con- 
trolling temporary hemorrhage. 




Fig. 466. — The author's tongue depres- 
sor devised for the tonsil operation, to be 
held by an assistant standing at the 
patient's head. 



4. The continuous rest in bed for from twenty-four to forty- 
eight hours minimizes the shock resulting from the anesthetic, the 
operation itself, and from the loss of blood. 

5. Finally, the dangers of secondary hemorrhage are over- 
come, inasmuch as trained attendants are at hand and no time is 
lost in the application of hemostats or other means of control. 

Next to operating in a hospital, the most favorable place is 
the patient's home, where he can be placed in bed as soon as the 
operation is completed. If possible a trained nurse or attendant 




Fig. 467. — Thomson's tenaculum tonsil forceps. 



should remain in charge for one night. The portable operating 
table. (Fig. 152) is convenient for operation at the patient's home. 
It is sometimes necessary and even feasible to operate upon adults 
under local anesthesia in the surgeon's office, but never when a 
general anesthetic is employed. 

The Anesthetic. — Ether, preceded by nitrous oxid gas, is the 
favored anesthetic except in very young children, when ether alone 
or chloroform may be employed. In general, ether is the safest of 
all anesthetics, and fewer fatalities have been reported than from the 
use of chloroform. Furthermore it is a distinct advantage both to 



CHRONIC INFLAMMATORY DISEASES. 725 

the operative technique and to the safety of the patient if the anes- 
thetist has had considerable experience in anesthesia for tonsil and 
adenoid operations. 

Local anesthesia of the tonsil is difficult to induce. Mere 
swabbing- of the external surface with cocaine solution is ineffective 
except upon the superficial areas. Injection into the crypts is 
slightly more effective, but also inefficient. The solution must be 
injected into the deeper areas, especially at the base of the tonsil 
and' the capsule (Fig. 464). When applied externally a 20 per 
cent, solution may be employed. Ballinger advises an aqueous 
solution containing cocaine, 10 per cent., and carbolic acid, 5 per 



3* 



— »r. 



Fig. 468. — Carter's tonsil tenaculum. 

cent. For hypodermic use the cocaine should not be stronger than 1 
per cent. A combination of equal parts of 1 per cent, solution of 
cocaine and adrenalin solution 1 : 3000 is commonly employed for 
hypodermic anesthesia. Unfortunately the hypodermic administration 
of adrenalin produces alarming symptoms in certain individuals. In 
three of the author's cases the injection has immediately been followed 
by alarming collapse, characterized by violent pain at the base of the 
brain and rapid respirations. 

The Operation. — When operating under general anesthesia the 
surgeon should have the aid of one assistant' and if possible a nurse. 



s| ^^; 



Fig. 469. — Leland's tonsil separator. 



The chief duty of the assistant is to depress the patient's tongue 
and sponge the throat. This duty may be assumed by the anesthe- 
tist or by a well-trained nurse. Under local anesthesia the patient 
may be instructed to depress his tongue. The patient should lie 
upon his back, with the head slightly lowered when operating under 
general anesthesia. When a local anesthetic is employed the upright 
position is preferable. 

Having completed all arrangements, including anesthesia (Fig. 
445), a bright electric headlight (Fig. 5), worn by the Operator, 
furnishes the most satisfactory illumination. A specially con- 
structed tongue depressor with a Ion- handle (Figs. 465 and 466) 
should now lie introduced 1>\ the assistant, whose position should 
be at the patient's head, while the operator stands at the patient's 



726 THE PHARYNX AND FAUCES. 

left side. In this position the assistant's hand and arm do not 
interfere with the operator. The tonsil is then seized by means of 
a curved long-tined tonsil forceps (Fig. 467) or Carter's tenaculum 
(Fig. 468), and drawn forcibly toward the median line of the 
pharynx. This procedure brings the free borders of the faucial 
pillars into full view. The primary incision is then made, prefer- 
ably through the line of attachment of the anterior pillar with the 
tonsillar capsule, by means of a long-handled curved bistoury (Fig. 
472), a tonsil separator (Fig. 469), the Douglas knife (Fig. 470), or 
Kyle's crypt knife (Fig. 471). Having separated the anterior 
portion (Fig. 472), the tonsil is rotated outward and a similar 
incision is extended through the posterior attachment and thence 



F\g. 470. — Douglass's tonsil knife. 

upward and around the supratonsillar fossa, the tonsil meanwhile 
being rotated downward in order to bring its velar lobe into view. 
A separator, preferably Hurd's (Fig. 473), is then employed to 
further release the tonsil from its attachments. A Moseley tonsil 
snare (Fig. 474) threaded with No. 8 piano wire is then thrown 
over the projecting tonsil and the tenaculum again applied. 
Forcible traction is made in the direction of the median line until 
by manipulation and gradual tightening of the loop the entire mass 
becomes engaged (big. 475). The wire loop is then gradually 
tightened until the mass is removed (Fig. 476). The opposite 
tonsil is then removed in like manner. The denuded space should 
then be carefully searched for any remaining shreds of tonsil tissue, 
and if found they should be snipped off with Myles's tonsil punch 



* Fig. 471. — Kyle'.s tonsil crypt knife. 

(Fig. 477). If hemorrhage persists a gauze sponge attached to the 
sponge holder (Fig. 449) should be pressed into the tonsillar fossa. 
In case pressure fails to control the hemorrhage, the bleeding 
point should be located and grasped with long hemostatic forceps. 
The vessel may then be twisted or ligated. Rosenheim has devised 
an ingenious ligature carrying hemostatic forceps (Fig. 478) for 
grasping and ligating the tonsillar blood-vessels. Occasionally 
it becomes necessary to apply the tonsillar hemostat (Figs. 479 and 
480) for a short period. After the removal of the tonsil a large 
oval cavity between the tonsillar pillars remains (Fig. 481), which 
contracts and fills in with granulations. Ballenger modifies this 
procedure by using the tenaculum forceps and the Kvle right 
angle tonsil knife for the greater part of the dissection, and a 




Fig. 471a.— In both primary and secondary hemorrhage its control 
should be attempted by means of gauze-sponge pressure, as described on 
page 726. Failing in this, the other methods described on pages 726 and 
727 should be resorted to and persisted in until the hemorrhage is fully 
controlled. This is affected with greater ease during the time the patient 
is still under the anesthetic. The above cut illustrates a new and ingenious 
method of controlling tonsillar hemorrhage. It is an adaptation of the 
Michel clamp suture (Wagener) to the tonsil. By inserting a gauze tampon 
into the cavity from which the tonsil has been removed, one point of the 
suture is applied to the anterior and its fellow to the posterior pillar. 
The introduction of two or three sutures is usually sufficient to draw the 
pillars over the gauze tampon with sufficient firmness to suppress the 
hemorrhage. No. 1 is the introducer. No. 2 is the extractor. 



CHRONIC INFLAMMATORY DISEASES. 



727 



tonsillotome for the final separation. He also has recommended 
the removal of the tonsil and its "capsule with knife (scalpel) and 
scissors, and, finally, by means of the scalpel alone. Robertson 
employs a specially devised tonsil scissors (Fig. 482) for excising- the 
tonsil. The Sluder operation is outlined in the legend of Fig. 477a. 
Dangers. — The chief danger attending operations upon the 
tonsil is hemorrhage, which arises from anomalous arterial dis- 
tribution, or as a result of the accidental wounding of some artery 
in the surrounding tissues. Secondary hemorrhage is not common, 




Fig. 472.— The primary incision for separating the hypertrophicd 
tonsil from its attachments. 



but when it does occur it is usually profuse and persistent. Fatal 
secondary hemorrhage is rare, and almost invariably it occurs in 
patients who are allowed to go to their homes soon after the oper- 
ation is completed. 1 An ingenious method of controlling tonsillar 
hemorrhage is to pack the denuded cavity between the pillars with 
gauze. The packing sometimes is retained by the pressure of the 
faucial pillars; otherwise a suture may be carried through the bor- 
ders of the pillars and be drawn taut across the space. The Michel 
clamp suture (Fig. 471a) is ideal for this purpose. The Miculicz 
Stoerck hemostat (Fig. 480) produces great discomfort, and if left 
too long in situ troublesome sloughing may occur. Hypodermics of 
human or horse serum may also be employed in severe cases. 

1 For further remarks on tonsillar hemorrl • nd under FMg. 171a. 



728 



THE PHARYNX AXD FAUCES. 



_ Complete Removal Without Including the Capsule.— The par- 
ticular steps of this operation are as follows :— 

1. Separate any existing adhesion between the faucial pillars 
and the tonsil. ' 

nr 2 '^ mov e the redundant portion of the tonsil with a McKenzie 
{big. 483) or Mathieu (Fig. 484) tonsillotomy 



^^ 



Fig. 473.— The Hard tonsil separator. 



3. Grasp the remaining base or denuded capsule with dull 
forceps or tenaculum held in the left hand, and draw it toward the 
median line; at the same time remove the remaining portion by 
means of a series of bites with the punch forceps (Fig 477) It is 




Fig. 474— The Moseley tonsil snj 



mportan to grasp the tissues of the supratonsillar space and draw 
its capsule downward into view in order to denude it of the last 
reH nf K J 6 ™ 1111 "? tonsil. The technique of this procedure is 
tedious but when thoroughly and skillfully performed the result is 
^ ery satisfactory. 



CHRONIC INFLAMMATORY DISEASES. 



729 



Partial Removal (Tonsillotomy). — As the name implies, the pur- 
pose of this operation is to remove as much of the tonsil as is 
possible by. means of some form of tonsillotome applied one or 
more times. As a rule, the redundant portion only is removed, 
but in exceptionally favorable cases it is possible to excise the 
entire tonsil with this instrument. As heretofore stated, to leave 
any portion of the tonsil and its base invites subsequent attacks of 
tonsillar infections, peritonsillar abscess and recurrence of hyper- 
plasia. Hence the objection to this procedure. Nevertheless, out- 
side of America, it still remains the most common method and the 
one in general use throughout the civilized world. The McKenzie 
tonsillotome (Fig. 483) is the standard instrument and the one most 




Fig. 475. — The tonsil snare applied to the loosened and evulscd tonsil. 



generally employed. The Mathieu tonsillotome (Fig. 484) has 
obtained almost equal popularity. The operation may be performed 
either with the patient in a sitting or recumbent position, and either 
witli or without general anesthesia. Under general anesthesia a 
mouthgag is necessary. When operating under local anesthesia 
the operator should sit facing the patient and reflect a bright light 
into his pharynx. An assistant should stand behind the patient. 
whose duties are to steady the patient's head and to make linn 
counterprcssure upon the tonsil from the outside. The tonsillotome 
should then he introduced exactly as a tongue depressor, and after 
depressing the tongue the handle' should lie swung outward toward 
the side to be operated upon, and at the same time made to engage 
the lower portion, and, finally, the entire tonsil, in its fenestrum. 
Firm lateral pressure is now made with the instrument against the 
assistant's external opposing digital pressure, and tin- blade is driven 
home. The'opposite tonsil should he similarly removed. 



730 



THE PHARYNX AND FAUCES. 



After-treatment. — The after-treatment is similar to that here- 
tofore described for adenoid operations (see Chapter XLIII). It 
is advisable, even when a local anesthetic has been employed, to 
recline for the balance of the dav, and to avoid hot food or drinks. 




Fig. 476. — Tonsils removed by dissection and snare, actual size. 
The capsule is intact. 

Cool drinks and cracked ice may be taken in moderation, and are 
gratefully borne. 

\ dulls usually complain of severe postoperative pain. Some 
relief may be obtained from the application of orthoform to the 

denuded surfaces. The complete operation is followed by more or 




Fig. 477.— The Myles 

tonsil punch. 



less local infection, which is more severe in adults. The sore- 
ness and dysphagia continue for several days, during which time 
soft food only can be taken. There is but little rise in temperature 
and alarming secondary symptoms are exceedingly rare. 

The cut surfaces soon become covered by a grayish-white 
slough which has a membranous appearance. After the second day 
it is advisable to cleanse the throat at intervals with alkaline sprays 
or gargles. 




f 



Fig. 477a. — (Sluder, with permission.) Sluder 1 has devised a unique 
method for the removal of the faucial tonsils. For this purpose he em- 
ploys a specially constructed dull-bladed Mackenzie tonsillotome, which 
both crushes and cuts when the blade is forced against the copper lining 
of the ring. The guillotine is passed backward from the opposite side of 
the mouth and the tonsil is engaged in a manner exactly opposite to that 
of the old method of removing tonsils with this instrument. Force is 
applied behind and below the tonsil and the latter is then pulled forward 
and upward about three- fourths inch against the alveolar eminence of the 
lower jaw. The latter acts both as resistance and at the same time forces 
the tonsil more completely into the ring of the guillotine. The unemployed 
hand is then used for the purpose of more thoroughly engaging the tonsil 
into the ring of the guillotine when the blade is driven home. As a rule. 
more or less of the tissue of the anterior pillar is cut away in the Sluder 
operation. The advantages claimed are rapid execution, minimum surgical 
violence, and less hemorrhage. 



1 Paper read before the American Medical Association, June 9, 1910, and published in 
the Journal of the American Medical Association, March 25, 1911 : Journal of the Missouri 
State Medical Association, March, 1913 ; Trans. Academy of ( thalmology and Oto- 
laryngology. 1912. 



CHRONIC INFLAMMATORY DISEASES. 



731 



Chronic Lacunar Tonsillitis. 

Synonym. — Chronic follicular tonsillitis. 

This is a chronic, hyperplastic inflammation of the tonsil char- 
acterized by accumulations of caseous material in the crypts. 

Etiology, — The disease probably occurs as a result of a series 
of attacks of acute lacunar or septic tonsillitis in which the epithe- 




ature carrying hemostat. 



Hum of the crypts is the chief seat of the disease. It is commonly 
associated with chronic peritonsillar abscess, and it may be caused 
by unhealthy and insanitary surroundings, or by chronic infection 
involving any portion of the upper respiratory tract. It is more 
common in adults than in children. 




Fig. 479. — Kurd's tonsil hemostat. 



Pathology. — In chronic lacunar tonsillitis the tonsil as a whole 
may not be extensively enlarged; but the crypts are usually quite 
numerous, and one or more arc filled with secretion. Retention "I 
secretion is m<»rc likely to occur in the crypts which open into the 
suprati msillar fossa. 

The so-called caseous material consists oi a series oi yellow 
masses or plugs which are located in the tonsillar lacuna'. Ii is 



732 



THE PHARYNX AND FAUCES. 



composed of desquamated epithelium, cholesterin, leucocytes, fatty- 
material, a variety of micro-organisms and particles of food. The 
masses are sometimes visible to the eye, but more often they are 
partially hidden by the pillars or wholly buried from sight and are 
discovered only by probing-. They are malodorous and of cheesy 
consistency. 

Symptoms. — Locally there is a sensation of fullness, roughness 
and irritability about the tonsil, with slight pain. Neurotic patients 
often are peculiarly susceptible to the slight pain and irritation, 
even when there is retention only in one or two crypts. Others 
are conscious of an offensive taste and odor and seek treatment 
chiefly for relief from these symptoms. Many patients are able to 
squeeze out these masses by pressure with the fingers. The largest 




l-'i' r . 480. — The Miculicz-Stoerck tonsil hemostat. 



aggregation is usually in the supratonsillar region and here the 
symptoms are pronounced. Acute exacerbations of lacunar tonsil- 
litis are common. 

Diagnosis. — Lacunar tonsillitis is likely to be mistaken for 
keratosis. The latter is rarely confined to the tonsil ; the masses 
project beyond the surface and are denser. Furthermore the 
deposits are firmly adherent and are whiter than the caseous accu- 
mulations in lacunar tonsillitis. 

Treatment. — Radical removal of the tonsil (described above) 
is the only method which promises permanent relief. Other meas- 
ures only afford amelioration of the symptoms. In patients who 
refuse operation and demand temporizing measures, two or more 
of the diseased crypts should be opened into each other by incising 
their dividing walls. In this manner the lacunar openings are 
enlarged, and retention is less likely to occur. After the incisions 
have been made the retained secretion should be removed by means 
of a ring curet and the cavity swabbed with a solution of argyrol, 
25 per cent., or a 20 per cent, solution of trichloracetic acid (Kauff- 



CHRONIC INFLAMMATORY DISEASES. 



733 



mann). Temporary relief is obtained from removal of the retained 
secretion, either by means of the ring- curet or by syringing out the 
crypts with a small cannula attached to a syringe. Pressure or 
squeezing with the finger also is an effective method. 



Cyst of the Tonsil. 

Tonsillar cysts usually result from inflammatory closure of 
the lacunar mouths, beneath which collections of caseous matter 
become encysted. They are also believed to result from traumatism 
and from the use of the galvanocautery. 




Fig. 481.— On the left side the cavity from which the tonsil has been 
removed is shown between the faucial pillars. 



Symptoms. — When the cysts are of small size the symptoms 
arc nil. Whenever the accumulation is sufficient to cause the tonsil 
to project into the oral cavity, a sensation of fullness results. Occa- 
sionally the cysts arc sufficiently large to make pressure upon the 
posterior pharyngeal wall and the base of the tongue, in which 
event the sensation becomes that of a foreign body with considerable 
irritation. 

Diagnosis. — The diagnosis is usually made without difficulty, 
inasmuch as pressure reveals the fluctuating character of the tumor. 
When the parietal wall is sufficiently thin the yellowish color is 
characteristic. 

Treatment. — The cyst should be freely incised, its contents 
scraped out. and the denuded surface painted with iodin, argyrol, 
25 per cent., or a solution of nitrate of silver 60 grs. to the ounce. 
As a rule, a tonsil which is the seat of a cysl is sufficiently diseased 
to require removal. 



734 



THE PHARYNX AND FAUCES. 



Tonsilliths (Calculi of the Tonsil). 

Etiology.-— Tonsilliths probably occur in a similar manner to 
that of tonsillar cysts, except that a deposit of lime salts becomes 
mixed with the retained caseous material. These deposits increase 




and solidify until calculi, or tonsilliths, of considerable size are 
formed. They are chiefly composed of calcium phosphate and car- 
bonate, with some organic material. They invariably occur in 
tonsils which are the seat of chronic lacunar inflammation. 




Fig. 483. — McKenzie's 
tonsillotome. 



Symptoms. — Until considerable size is reached no special 
symptoms are produced. The larger ones induce considerable 
inflammation of the surrounding tissues, and sometimes ulceration, 
in which event pain and dysphagia are experienced. 

Diagnosis. — The diagnosis is based upon the characteristic 
hardness of the tumor, which is conveyed to the probe or to the 
finger. 






CHRONIC INFLAMMATORY DISEASES. 



735 



Treatment. — The tonsillith should be removed through an 
incision of sufficient size to permit the introduction of a pair of 
strong forceps. The tonsil should also be removed. 

The Lingual Tonsil. 

The lingual tonsil, being a part of the so-called Waldeyer's 
ring of lymphoid glands, is located behind the circumvallate papillae, 
at the base of the tongue (Fig. 485) and above the epiglottis. It 




The Mathieu tonsillotome. 



is subject to both acute and chronic inflammation and it sometimes 
becomes permanently enlarged, in which event it gives rise to 
characteristic symptoms. The hyperplasia is usually bilateral, and 
large veins may radiate between the lymphoid masses. 

Symptoms. — The chief symptoms are a sensation of tickling, 
an irritating cough and impairment of voice. In singers and public 



Fi£ 




The lincmal tonsil and lingual varix. 



speakers all the symptoms are aggravated, especially the inter- 
ference with tone production. The sensation of a Foreign bod) 
causes constant annoying attempts al swallowing, without relief. 

Treatment. — Excision is the only effective treatment, and is 
besl accomplished by means of the Myles lingual tonsillotome I Fig. 
486). Local anesthesia is easily produced, providing a drop or two 
of a 1 per cent, solution of cocaine is injected directly into the mass 
ten minutes before operating, or a 10 per cent, solution of cocaine 
may be applied locally. The arrangements for operating are 



736 THE PHARYNX AND FAUCES. 

similar to those for intralaryngeal work, the patient holding his 
own tongue, and the operator, under bright reflected illumination, 
introducing the laryngeal mirror (Fig. 19) with his left hand, thus 
bringing into view the entire mass to be excised, and with the right 
hand guiding the instrument until a portion of the mass protrudes 
through its fenestra. Considerable hemorrhage may follow the re- 
moval, but it is controllable by pressure with adrenalin-soaked swabs. 
Care should be taken not to cut into the underlying cellular tissue. 
Removal may also be accomplished with a snare. 

After-treatment. — The patient should avoid hot drinks or the 
swallowing of coarse or solid food for twenty-four hours, after 
which the soreness rapidly subsides without further treatment, 
except that he should gargle with a cleansing solution immediately 
after taking food. Public speakers and singers should refrain from 
their usual occupations during the healing process, thus avoiding 
undue muscular strain. 




IV. LINGUAL VARIX. 



Lingual varix is made up of an aggregation of varicose veins 
located at the base of the tongue, between the circumvallate papillae 
and the epiglottis (Fig. 485). 

Etiology. — They are commonly observed in connection with 
hyperplasia of the lingual tonsil, but generally are due to some 
disease in which there is obstruction to the return circulation. In 
plethoric and alcoholic individuals, who suffer from cirrhosis of 
the liver, the disease is common. It may be caused by excessive 
use or improper production of voice. It is more common in males 
than in females and does not occur in childhood. 

Symptoms. — Lingual varix gives rise to a sensation of fullness 
in the throat and a tendency to cough. There is a sensation of 
dryness, with an almost continuous effort to relieve by swallowing 
or coughing. In rare instances the small veins rupture, but severe 
hemorrhage rarely occurs. Upon examination with the laryngeal 
mirror the varicose veins are plainly visible. 

Diagnosis. — The diagnosis is made by simple inspection, which 
reveals the dark-blue distended veins running anteroposteriorly in 
fan-shape, from the base of the tongue. 

Treatment. — Obliteration of the enlarged veins affords the 
only relief, and this is best and most safely accomplished by the 
galvanocautery puncture, under local anesthesia. The electrode, at 
a cherry-red heat, carefully guided into position by means of a 
laryngeal mirror, should be made to sever two or three of the large 
veins at a single sitting. "With the cautery at a cherry-red heat 
there is less danger of subsequent hemorrhage. Should' excessive 
hemorrhage result it is best controlled by pressure. 



CHAPTER XLVII. 
DISEASES OF THE PHARYNX. 



1. NEOPLASMS OF THE PHARYNX. 

1. BENIGN NEOPLASMS. 

The principal non-malignant growths observed in the pharynx 
are papillomata, fibromata, angiomata, adenomata, and dermoid 
cysts. 

Papillomata. 

Of the. benign neoplasms the papilloma is the commonest. The 
usual site is upon the uvula, but occasionally they develop upon 
the pillars, the soft palate, or the posterior and lateral pharyngeal 
walls. They are pedunculated, pale in color and occasionally 
sessile. They give rise to no symptoms, and usually do not grow 
larger than a pea. In rare instances they grow rapidly, reaching a 
size sufficient to produce a tickling sensation and paroxysmal 
cough. 

Treatment. — When they are of small size and produce no 
symptoms they may safely be allowed to remain. Otherwise they 
should be promptly removed under local anesthesia. The tumor 
should be firmly grasped with forceps, drawn away from its attach- 
ment and severed by means of scissors, knife, snare or cutting 
forceps. By including a small area of surrounding membrane, 
recurrence is prevented. Hemorrhage is never excessive, and no 
after-treatment is required, except that relating to cleanliness. 

Fibromata. 

Fibromata are rare in the oropharynx ; they occur during full 
adult life, and are more common in males. They are usually sessile, 
but may be pedunculated and may appear upon the velum, the 
faucial pillars, or the posterior pharyngeal wall. They are dense, 
solid to the touch, and light pink in color. When of large size they 
gradually become lobulated. Small ones produce no symptoms, but 
those of large dimensions give rise to functional disturbances, espe- 
cially dysphagia and dyspnea. 

Treatment. — The treatment is removal by operation. Small 
pedunculated growths are easily removed by means of the cold-wire 
or galvanocautery snare. When the attachment covers a large 
surface a circular incision should be made through the membrane 
surrounding the base of the growth ; the latter is then grasped with 
strong forceps and its attachment severed by means of snare or 

47 (737) 



738 THE PHARYNX AND FAUCES. 

scissors. Considerable hemorrhage may be expected, but it is 
easily controlled by pressure. Healing is facilitated by closing the 
wound with sutures. For the removal of fibromata of extreme size 
extensive surgical measures are sometimes required. 

Angiomata. 

Angiomata occur with about the same frequency as fibromata, 
and are made up of a network of blood-vessels, whose walls are 
held loosely together by connective tissue. There is no known 
cause. They usually appear upon the uvula, velum or faucial 
pillars. In a case reported by the author 1 (Fig. 487) there was a 
very large angioma involving the uvula and a portion of the velum. 
The patient was a male, aged 31. The uvula was enormously 
elongated and enlarged laterally, being made up of a mass of dilated 
blood-vessels. The tip extended well down into the glossoepiglottic 
space and seriously interfered with deglutition and respiration. He 
was constantly trying to swallow his uvula. At the time of opera- 
tion extensive preparations were made to control hemorrhage, 
which, it was feared, might be excessive. The entire mass was 
removed with a galvanocautery snare and with no hemorrhage 
whatever. 

Treatment. — Whenever feasible the growth should be removed, 
even at the risk of troublesome hemorrhage. When peduncular 
the galvanocautery snare is the ideal method. Those with broad 
attachments are amenable to the galvanocautery puncture, from 
three to five blood-vessels being destroyed at each sitting. Strangu- 
lation by means of a series of ligatures and destruction of the 
growths by electrolysis have been advocated. 

Adenomata. 

Adenomata may appear upon the soft palate, uvula, tonsil or 
the pharyngeal walls. They develop only during adult life and 
are difficult to distinguish from fibromata. Adenomata develop 
slowly, are less dense and less painful than fibromata. 

Treatment. — The only rational treatment is removal by surgical 
operation under general anesthesia, first dividing the membrane 
sufficiently to allow the operator to gradually enucleate the growth. 
In smaller growths a single primary incision over the central 
portion of the growth is sufficient. 

Dermoid Cysts. 

These are congenital and due to abnormalities of development. 
They are usually pedunculated and consist of a covering of ordi- 
nary integument, with hair follicles. Within the growth are found 
fatty matter, intermingled with portions of muscular fibre, cartilage 
and bone. 



New York Medical Record, March 12, 1887. 



DISEASES OF THE PHARYNX. 



739 



Treatment. — They should always be removed. The operation 
is simple. The mass is grasped with strong- forceps, while the 
pedicle is clipped off close to its attachment. 

2. MALIGNANT NEOPLASMS. 

Sarcomata and carcinomata of various types, both primary and 
metastatic, occur with comparative frequency in the oropharynx. 
Unfortunately, the etiology of malignant neoplasms has not yet 




Fig. 487. — Large angioma of the uvula removed by the galvanocautery 
snare without hemorrhage. (Author's case.) 

been determined. The pathology, symptomatology, diagnosis and 
treatment, being similar for both types of malignant diseases of the 
pharynx, will be described together. 



Sarcomata. 

Sarcomata of all types are found in the fauces and pharynx, 
and an_\' portion of the pharynx may become the primary seat of the 
disease. Primary sarcoma of the pharynx usually runs a rapid 
course, with a fatal issue. In exceptional cases the progress is slow, 
and six or eight years may elapse before the disease terminates. 



740 THE PHARYNX AND FAUCES. 

Ulceration occurs early and it is invariably followed by enlarge- 
ment of the neighboring lymphatic glands and general metastasis. 
The author has recorded two cases of melanotic sarcoma with deposits 
in the mouth, nose, pharynx and larynx. 

Carcinomata. 

Carcinomata rarely occur in the pharynx under the fortieth 
year, after which the ratio increases with age until advanced life. 
The disease is more common in males than in females, and the 
epithelial variety is the rule. 

Pathology. — The reader is referred to the numerous extensive 
treatises extant for the pathology of malignant neoplasms of the 
pharynx. 

Symptoms. — The symptoms of malignant neoplasms of the 
pharynx are dependent upon the location and extent of the growth. 
Pain is the most common of all symptoms, but may be absent during 
the earlier stages and it is more severe in carcinomata. As the tumor 
increases in size or when ulceration is present the pain becomes severe 
and lancinating, and deglutition becomes difficult. Dyspnea is marked 
whenever the tumor encroaches upon the lumen of the respiratory 
tract. As a rule, the earliest symptom complained of is a sensation 
of fullness and swelling in the throat. The later symptoms are severe 
pain, dysphagia, dyspnea, fetid breath, cachexia, cervical lymphatic 
enlargement, emaciation and hemorrhage. 

Diagnosis. — During the early stages it is often extremely dif- 
ficult to differentiate malignant from non-malignant growths, espe- 
cially tertiary syphilis. In case syphilis is suspected large doses 
of iodid of potassium should be administered in order to verify the 
diagnosis. A microscopic examination of a section of the growth 
furnishes the most reliable diagnostic data. Early diagnosis is of 
the utmost importance, inasmuch as the early and complete surgical 
removal of the growth offers the only hope of cure. 

Prognosis. — Without treatment malignant neoplasms of the 
pharynx terminate fatally. The prognosis is slightly favored where 
early and complete removal of the growth has been accomplished. 
The prognosis in sarcoma is slightly more favorable than in the 
other forms, but under all circumstances is grave. 

Treatment. — Radical surgical removal of the growth, instituted 
early in the history of the disease, is the only known means for 
terminating its ravages. The location and extent to which the 
growth has progressed are the chief determining factors regarding 
the advisability of even attempting any operative procedure. Under 
the most favorable circumstances recurrence usually takes place. 
Unfortunately, the majority of malignant tumors of the pharynx 
when first seen have already passed beyond all hope of benefit from 
surgical interference. Under these circumstances the tumor must 
be considered inoperable, and palliative measures only are admis- 
sible. 



DISEASES OF THE PHARYNX. 741 

If an operation is undertaken it is important that a consider- 
able area of the sound tissue surrounding the tumor should be 
included in the excision, and that all infected glands should be 
dissected out. Providing the diagnosis is made sufficiently early, 
and the growths are confined to the soft palate, the faucial pillars, 
the tonsil or peritonsillar tissue, it is possible to successfully 
operate within the mouth. General anesthesia is necessary. If the 
area of the disease includes the epiglottis, or the laryngopharyngeal 
space - , with or without lymphatic gland enlargement, and in all 
cases of metastasis, the external operation is required. The exter- 
nal operation is a serious procedure not only because of the dan- 
gers which usually accompany operations in this field, but for 
the further reason that in the majority of cases the disease has 
extended beyond the areas which the symptoms have indicated. 
Recurrence is the rule, yet the span of life may be prolonged for at 
least a few months, unless the patient succumbs to the shock or 
other dangers incident to operation. 

The incisions and methods of removal must be suited to the 
individual case, inasmuch as variations are made necessary by the 
location and extent of the disease. It is beyond the scope of this 
work to describe and to illustrate in detail the technique of the 
various operations, for which the reader is referred to works on 
general surgery. 

After-treatment. — The after-treatment includes simple meas- 
ures for maintaining cleanliness until healing has been complete. 

Treatment of Inoperable Cases. — Inoperable growths often 
require surgical interference for the relief of urgent and dangerous 
symptoms. Encroachment upon the lumen of the larynx or the 
pharyngoesophageal opening may be relieved, temporarily, by the 
removal of a large section of a projecting tumor, this procedure 
being best accomplished with the galvanocautery snare. Later 
developments may require tracheotomy or gastrotomy, the latter 
procedure being necessary for the purpose of feeding. The same 
procedure may be resorted to when recurrence has taken place. 
When the pain becomes intolerable, sufficient morphine should be 
given for the relief of this distressing symptom, and the surface of 
the tumor should be kept clean by proper sprays and washes. 
Various non-surgical methods have been advised, for Jhe relief or 
cure of inoperable cases. 

The value of treatment by X-ray, serum therapy (Coley's 
mixed toxins of bacillus prodigiosus and streptococcus erysipela- 
tis), etc., and the enzyme treatment (trypsin and amylopsin) have 
already been defined in Chapter XLIT. 

2. NEUROSES OF THE PHARYNX. 
1. MOTOR NEUROSES. 

Neuroses of the pharynx rue of two general varieties, the motor 

and the sensory. Motor neuroses appear in two general forms: 
(a) spasmodic affections; (b) paralysis. 



742 THE PHARYNX AND FAUCES. 

(a) Spasmodic Affections. 

Spasm of the pharynx is observed with hysteria, chorea, 
tetanus, hydrophobia, epilepsy and in certain forms of nystagmus. 

1. Globus Hystericus. — This occurs, as a rule, in women who 
have deep-seated irritability of the central nervous system. In rare 
instances it seems to be a reflex irritation caused by inflammatory 
changes in the tissues of the pharynx. The sensation is that of a 
lump rising in the throat, with spasm of the pharyngeal muscles. 
It is greatly aggravated by lingual varix or hypertrophy of the lingual 
tonsil. 

2. Chorea (Choreic Movements). — Spasmodic twitchings of the 
muscles of the soft palate and pharyngeal walls are often symptoms 
of chorea, and, occasionally, of paralysis agitans. Similar contrac- 
tions may occur in neurotic patients who are suffering from pharyn- 
geal inflammation, foreign bodies, or tumors. 

3. Nystagmus. — Pharyngeal nystagmus, with rare exceptions, 
is a manifestation of some serious central lesion like brain abscess 
or tumor, meningitis, general paralysis or tabes dorsalis, and is 
never confined to the pharynx or larynx. In rare instances a 
rhythmical muscular movement of the velum palati accompanies 
local lesions in the upper respiratory tract. 

Treatment. — Before instituting treatment a general examina- 
tion of the patient should be made in order to determine if possible 
the exact cause of the affection. Some form of general treatment 
is usually required. Rest, improvement of the diet, change of loca- 
tion and general tonics are indicated. In globus hystericus the 
bromids, asafetida and valerianate of zinc are useful in controlling 
spasm. Some benefit is claimed from applications of the faradic 
current to the back of the neck, and interiorly to the pharyngeal 
walls. Diseased conditions within the pharynx should receive 
attention and full advantage should be taken of all slight operations 
or applications to secure the benefits of suggestive therapy. 

For the treatment of chorea, hydrophobia, and epilepsy the 
reader is referred to works on diseases of the nervous system. 
Nystagmus of central origin is always a grave condition. 

(b) Paralysis. 

Paralysis affecting the pharyngeal muscles is usually confined 
to those of the soft palate, but it may involve the constrictors. 
The affection may be of central origin, resulting from cerebral 
embolism, cerebral tumors, tabes dorsalis, and bulbar paralysis. 
It also arises from pressure upon the nerve trunks, either in the 
form of gummata or new growths. A third and common form of 
paralysis of the pharynx is of peripheral origin, resulting from the 
toxins of diphtheria and influenza, and from mineral poisons. When 
bilateral the entire velum and uvula drop downward and forward 
away from the posterior pharyngeal wall, and do not give motor 
response to voice and other sounds. In young persons the com- 



DISEASES OF THE PHARYNX. 



743 



monest form is that which follows as a sequela of diphtheria and 
streptococcic infection. In unilateral paralysis, upon examination 
the uvula is drawn toward the non-affected side, while the paralyzed 
half of the velum palati drops into the pharyngeal space (Fig. 488). 
There is a nasal quality to the voice and during deglutition a 
portion of the fluids passes into the nasopharynx and out through 
the nose. 

Treatment. — The treatment of cases of central origin should be 
advised by a competent neurologist, inasmuch as the pharyngeal 
paralysis usually is but a part of a more general paralysis. Gum- 
mata respond to the internal administration of potassium iodid. 
Other tumors if possible should be removed. The paralysis of 




Fig. 488. — Unilateral paralysis of the velum palati. 

diphtheria disappears without treatment after an interval of about 
one month, but tonics should be administered. Locally, some 
benefit may be expected from the application of the faradic current. 
Outdoor life, simple but liberal diet, and freedom from all depress- 
ing influences are of great benefit. 

2. SENSORY NEUROSES.' 

Sensory neuroses of the pharynx occur in the form of anesthe- 
sia, hyperesthesia, paresthesia and neuralgia. 



Anesthesia. 

Anesthesia, whether complete or partial, unilateral or bilateral, 
usually accompanies motor paralysis; but it may be a symptom 

of hysteria or insanity, resulting from pressure upon the glosso- 
pharyngeal nerve. 



744 THE PHARYNX AXD FAUCES. 



Hyperesthesia. 

Hyperesthesia accompanies a large proportion of all cases of 
acute and many cases of chronic pharyngeal inflammation. It is 
invariably bilateral, and is aggravated in alcoholic, tuberculous and 
dyspeptic individuals. 

Paresthesia. 

Perversions of sensation, designated as paresthesia of the 
pharynx, are of neurotic origin. Parker has noted the affection as 
an accompaniment of sexual hypochondriasis in the male and the 
climacteric period in the female. The affection is characterized by 
a sensation of suffocation, itching, hawking or a barking cough, and 
tickling as of a foreign body in the throat. 

Treatment. — The conditions above described usually require 
internal medication in the form of tonics (iron, strychnine, and 
cod-liver oil). Sedatives also may be required (bromids, valerianate 
of zinc, asafetida). Local treatment in the form of mild astringents 
and sedatives is helpful. In neurotic patients it often is wiser to 
desist from all local treatment in the pharynx in order to divert 
attention from the trouble. The underlying cause of the particular 
symptoms should be sought and if possible removed. It is espe- 
cially important to divert the patient by change of scene, rest, 
cessation from pernicious habits, and avoidance of worry and care. 



3. UNCLASSIFIED AFFECTIONS OF THE PHARYNX. 

FUNGOID GROWTHS IN THE PHARYNX. 

Fungoid affections occurring in the pharynx are of two varie- 
ties : (a) thrush ; (b) keratosis. 

(a) Thrush. 

Thrush is an affection of the mouth and pharynx, resulting from 
yeast fungi which are termed saccharomyces albicans or oidium 
lactis. It is more common in infants and in the aged, but is some- 
times observed in adults during the later stages of typhoid fever 
and other severe and prolonged illnesses. 

Pathology. — The pathogenic species under consideration induce 
a growth of thrush upon the surface of the mucosa of the mouth 
and pharynx, which is characterized by the appearance of wdiite 
cylindrical or oval cells about the size of a small bead. They some- 
times form into long filaments or gradually coalesce into small 
patches. 

Symptoms. — There are no characteristic subjective symptoms. 
There is but little pain, but the affection is usually accompanied by 
digestive disturbances. 

Treatment. — Whenever the disease is local and unattended 
with severe symptoms, relief will usually follow a thorough clean- 



DISEASES OF THE PHARYNX. 745 

ing of all implements of the dietary, especially the nufsing bottles. 
At the same time the mouth should be thoroughly sponged with 
boric acid solution after each feeding. Regulation of diet and 
hygiene are important. 

(b) Keratosis. 

Synonyms. — Hyperkeratosis (Wood), mycosis of the pharynx, 
pharyngomycosis, mycosis leptothrix. 

According to Wood, keratosis of the pharynx is an affection 
characterized by the development of white horny masses, which 
project chiefly from the orifice of the tonsillar crypts, but which 
may project from the orifices of any lymph follicles situated in the 
pharynx. This affection is more common between the ages of 
twenty and forty. 

Pathology. — Examination of the pharynx reveals an aggrega- 
tion of whitish conical excrescences standing out well beyond the 
orifices of the lymph follicles-, to which they are firmly adherent. 
In the tonsils the crypts become distended with a horny mass which 
is arranged in layers, and between which various organisms mul- 
tiply and grow. They vary in size from a pinhead to a kernel of 
rice. The parts affected are usually the faucial and lingual tonsils, 
lateral pharyngeal walls, and base of the tongue. 

Symptoms. — As a rule, there are no symptoms and the disease 
is accidentally discovered while inspecting the throat. At the base 
of the tongue they are liable to irritate the epiglottis and produce 
a sensation of roughness and tickling in the throat. 

Diagnosis. — Keratosis may be mistaken for chronic lacunar 
tonsillitis. In keratosis the masses are tough,, firmly adherent, and 
difficult to remove. Furthermore, keratosis is not invariably con- 
fined to the area of the tonsil. 

Treatment. — The symptoms are rarely of sufficient severity to 
necessitate treatment, and spontaneous recovery usually takes place 
after a considerable period of time. Forcible removal (if the masses 
is usually followed by recurrence. In cases where the symptoms 
are annoying to the patient it is feasible to destroy the offending 
masses by means of the galvanocautery puncture, the process 
requiring penetration through the mass into the lymph follicles for 
a distance of at least four millimetres. The inflammatory reaction 
from the galvanocautery is considerable; hence, but few punctures 
should be made at one sitting. 



SECTION III. 

The Larynx. 



CHAPTER XLVIII 
ACUTE INFLAMMATORY DISEASES. 

Anatomical Points of Interest. — The anatomical landmarks of 
the larynx of interest to the surgeon are depicted in the accompany- 
ing illustrations from Deaver's "Surgical Anatomy of the Head and 
Neck." Anatomy of the superior aperture of the larynx is shown 
in Fig. 489; that of the external anterior surface in Fig. 490; that 
of the external posterior surface in Fig. 491 and the interior lateral 
view in Fig. 492. 

1. ACUTE INFECTIOUS EPIGLOTTITIS. 

Synonyms. — Acute epiglottitis ; angina epiglottidea anterior 
(Michel). 

The term acute infectious epiglottitis is used to define a 
primary acute infection which is limited in area to the epiglottis. 
Cases of this type have been reported by Michel and Theiseri, 
wherein the inflammatory process was confined to the anterior 
surface of the epiglottis and usually with edema. Kyle does not 
believe that the disease under consideration exists except in con- 
junction with an associated laryngitis. The author has observed 
one case of this type in a man forty years old who apparently had 
developed a primary local edema of the anterior surface of the 
epiglottis, but upon close inspection congestion of the intralaryn- 
geal mucosa was evident. 

Hajek has shown that the mucous membrane of the anterior 
surface of the epiglottis is less adherent than on the posterior 
surface; for this reason edema of the anterior surface is more 
common. 

Diagnosis. — The diagnosis is based upon the characteristic 
symptoms, viz. : a sudden attack of inflammation of the tissues 
overlying the epiglottis, attended with fever, swelling and edema, 
which is limited chiefly to its lingual surface, and painful deglu- 
tition. It should be differentiated from angioneurotic edema, which 
develops without fever, the edematous tissue of the latter being a 
grayish color, and from acute infectious laryngitis, by the absence 
of laryngeal symptoms. 

Treatment. — At the outset the patient should be placed in bed 
with the head elevated. The administration of calomel and salines 
produces a favorable effect. The chief indication for treatment of 
(746) 



ACUTE INFLAMMATORY DISEASES. 



'47 



the local lesion is to relieve the edema. This is best accomplished 
by a series of incisions of sufficient depth to afford drainage to the 
waterlogged tissues. The scarifier devised by Tobold (Fig. 495) 
is a safe and convenient instrument for this purpose. 




Fig. 489. — Superior aperture of the larynx. (Deaver, with permission.) 
a, vocal band; 4. ventricular band; c, tonsil; d, adenoid tissue at base of 
tongue; e. foramen cecum; f, posterior wall of pharynx; o, corniculum laryntris ; 
h, cuneiform cartilage; i, epiglottis; *. median glossoepitdottic fold; /, fungiform 
papillae; m.circumvallate papillae. 

Relief by means of scarification is not invariably permanent, 
and it is often necessary to repeat the scarification at intervals. A 
patient suffering with this disease should not be left unattended 
by the surgeon or his assistant until the edema has sufficiently 
subsided and all danger of suffocation has passed, inasmuch as 
fatal cases have been reported. A tracheotomy tube should be at 
hand in order to meet the emergency of urgent dyspnea. Ice-bags 



748 THE LARYNX. 

applied over the anterior surface of the neck have been recom- 
mended, and iced sprays containing ichthyol have been used with 
success by Meyjer, while Tyson used a l /z per cent, solution of 
ichthyol applied locally to the epiglottis every half hour during the 
acute stage. A spray solution of the following ingredients is of 
great benefit : — 

B Tannin glycerid, 
Lemon juice, 
Sol. adrenalin chlorid, 1:10,000, 

Normal salt solution aa 3ij. 

Sig. : Keep in cold place and spray larynx every half hour or every 
hour. 

2. SIMPLE ACUTE LARYNGITIS. 

Synonyms. — Acute catarrhal laryngitis; laryngorrhea. In 
young children the disease is termed spasmodic croup, or spasmodic 
laryngitis. 

AS OBSERVED IN ADULTS. . 

This disease is characterized by an acute inflammatory process 
involving the laryngeal mucosa. It rarely occurs as a purely local 
affection, the laryngeal inflammation being merely part of a more 
general attack which involves the upper respiratory tract and often 
the trachea and bronchi as well. While annoying on account of the 
attendant dryness and hoarseness, it is usually trivial in its conse- 
quences, except to singers, teachers and public speakers, who 
become temporarily incapacitated thereby. Certain individuals are 
subject to recurrent attacks, especially during the spring and fall 
change of seasons. 

Etiology. — Simple acute laryngitis is caused in exactly the 
same manner as that more common affection, simple acute rhinitis 
(see Chapter XXXIII). The chief predisposing factors are chronic 
rhinitis, obstructive nasal lesions, chronic laryngitis, abuse of alco- 
hol and tobacco, eruptive fevers, bodily fatigue, and certain systemic 
disturbances, especially those of vasomotor, digestive and toxic 
origin ; while overwork, sedentary habits and bad hygiene, by 
lowering the bodily resistance, become causative factors. Of the 
exciting causes, undue bodily exposure, especially of the feet, the 
inhalation of noxious gases and emanations, and bad ventilation are 
the chief. 

Pathology. — The pathological changes are identical with those 
observed in other portions of the respiratory tract under similar 
conditions and heretofore described (Chapter XXXIII), with the 
same stages, but with less secretion, owing to the fact that gland- 
ular development in the larynx is meagre. During the initial stage 
there is congestion and engorgement of the blood-vessels, followed 
by infiltration of the mucosa with leucocytes and round cells, the 
latter condition tending to diminish the lumen of the larynx. This 
stage is soon followed by the appearance of exudate, the character 



ACUTE INFLAMMATORY DISEASES 



of which is thin and watery 
at first, but, owing to the 
desquamation of epithe- 
lium, it gradually becomes 
denser and lighter in color. 
Occasionally the inflamma- 
tory process extends to the 
muscles, when the move- 
ments of the arytenoids 
and vocal cords become 
impaired. 

Symptoms. — At the 
commencement there is 
slight chilliness, lassitude 
and some rise of tempera- 
ture, with a distinct sensa- 
tion of burning, itching or 
tickling within the larynx. 
This is soon followed by 
hoarseness and a dry, hack- 
ing cough. During the 
second stage the symptoms 
are all aggravated, phona- 
tion often becoming pain- 
ful, hoarseness marked, and 
complete loss of voice may 
ensue. 

Cough continues, ex- 
pectoration is scanty, and 
dysphagia may be com- 
plained of. The tempera- 
ture rarely rises above 
102°. The inflammation 
is general throughout the 
entire mucosa, with suffi- 
cient swelling to interfere 
with the mobility of the 
parts. Edema is rare. At 
the commencement of the 
third stage a mucopurulent 
secretion appears, which 
relieves the dryness. The 
cough becomes less rasp- 
ing, pain subsides, and re- 
covery gradually ensues. 
Slight hemorrhages some- 
times occur as the result 
of the severe strain pro- 
duced upon the congested 
membranes by the par- 




Fig. 490.— Anterior external structures of the 
larynx. (Deaver, with permission.) 
a, greater cornu of byold bone; b, lesser cornu 
of hyoid bone; C, lateral portion of thyro hyoid 
membrane; </, internal laryngeal nerve; e, superior 
laryngeal ,,n, , N ; /, thj mid cartilage; <;. i rieo 
thyroid membrane; //, erieo-thyroid muscle; i, 
lateral lobe of thyroid gland; I, trachea; /. 
isthmus of thyroid gland; t, epiglottis; 8, hyoid 
bone; r, central portion of thyro-hyoid membrane; 
v. inferior constrictor muscle of pharynx; p, 
superior thyroid artery; o, erieo-thyroid artery; 
n, levator glandulse thyroideae muscle; m, cricoid 
cartilage; Ic, inferior thyroid veins. 



750 



THE LARYNX. 



oxysras of coughing. Objectively, the laryngeal mucosa appears 
intensely inflamed, the vocal cords are red and sometimes dotted 
with small areas of ecchymosis. The infiltration, which involves 
the arytenoids, ventricular bands and rim of the epiglottis, inter- 
feres with the free movement of the vocal cords. Accumulations 
of secretion are visible, especially in the posterior commissure. 

Prognosis. — With proper care and treatment the disease is not 
serious and recovery takes place in from four to seven days. In 
neglected, cases occurring in persons with lowered vitality from 

any cause, or those who suffer 
from chronic laryngitis, the in- 
flammation and infiltration may 
persist for some time. Re- 
peated attacks tend to estab- 
lish a chronic laryngeal inflam- 
mation. 

General and Preventive 
Treatment. — The necessary 
measures for general treatment 
are those already described for 
acute catarrhal ^rhinitis (see 
preventive treatment of acute 
rhinitis), and if instituted early 
terminate the attack. 

Local Treatment. — If se- 
vere, with rise of temperature, 
the patient should be advised 
to remain in a warm room, and 
in the case of singers and 
public speakers the voice 
should be given complete rest. 
All conversation should be in 
whispers. Free calomel and 
saline purgation is of inestim- 
able value. The application of 
a cold compress or an ice-coil 
to the larynx for a few hours 
during the early stage of the 
disease tends to retard and 
diminish the inflammatory pro- 
cess. Cough should be con- 
trolled in order to minimize 
the muscular movements of the 
larynx. A useful sedative will 
be found in codeine, gr. y\ to ^2 every four hours, or heroin, 
gr. %4 every three hours. The intralaryngeal applications of strong 
astringents sometimes advised are harmful, since they cause severe 
pain, aggravate the symptoms, and never are beneficial. Applica- 
tions to the membranes should invariably be of a soothing nature. 
Insufflations are likewise ill-advised on account of the paroxysms 




Fig. 491. — Posterior external struct- 
ures of the larynx. (Denver, with per- 
mission.) 

a, laryngeal surface of epiglottis; 6, mus- 
cular process of artenoid cartilage; c, cricoid 
cartilage; d, trachea; e, aryepiglottic fold; 
f, aryepiglottic muscle; g, arytenoideus mus- 
cle; h, thyroid cartilage: /, posterior crico- 
arytenoid muscle; ;, recurrent laryngeal 
nerve. 



ACUTE INFLAMMATORY DISEASES. 



751 



of cough which they produce. The diaphoretic effect of a hot mus- 
tard footbath in conjunction with a hot draught of lime or lemonade 
is soothing and hastens the stage of exudation. 

The following may be administered as an expectorant : — 

IJ Ammonii chloridi 3ss. 

Syr. scillse, 

Syr. Tolutani, 

Spr. seth. nitrosi aa. 3j. 

Elix. simp q. s. ad 3iv. 

M. Sig. : Teaspoonful every four 
hours. 

Much relief to the dry, inflamed 
membranes may be obtained from 
medicated steam inhalations. Any 
reliable form of inhaler (Fig. 497) 
will suffice. To the boiling water 
may be added 10 drops of spirits of 
camphor, 10 grains of menthol, or a 
dram of compound tincture of benzoin 
to the pint. The inhalations should 
continue about ten minutes and be re- 
peated every two hours. Vapors of 
'creosote and eucalyptol have likewise 
been recommended, but are less effica- 
cious. Mild counterirritants over the 
larynx in the form of sinapisms, or 
rubbing with a mixture of equal 
parts of turpentine and olive-oil, 
may allay the cough during the 
second stage, and at night it may 
become necessary to relieve the 
tickling sensation in the larynx by 
the use of some form of lozenge, 
to be gradually dissolved in the 
mouth. One composed of codeine, 
gr. y 10 , and camphomenthol, gr. % , 
has proven most efficacious in the 
author's practice. 

By promptly resorting to the 
foregoing measures an acute attack 
may be partially aborted, with com- 
plete recovery in from thirty-six to 
forty-eight hours. Immediate relief, 
in order that an engagement may be filled, is often demanded by 
persons professionally engaged — singers, public speakers, etc. 
Such individuals should be strongly advised against singing or 
speaking when the larynx is acutely inflamed, and warned that the 
attempt is fraught with considerable danger of producing a long- 
continued laryngitis, prolonged weakness and inefficiency of the 
laryngeal muscles, and possible sufficient damage to the voice to 




Fig. 492.— View of the internal 
lateral structure of the larynx. 
(Deaver, with permission.) 

a, epiglottis; g, false vocal cord; 
i, ventricle of larynx; b, true vocal 
cords; C, lateral portion of crico-thy- 
roid membrane; (1, central portion of 
crico-thyroid membrane; e, cricoid 
cartilage; f, trachea; 7(, aryteno-epi- 
glottidean fold; ;, corniculum laryn- 
gis; Jc, arytenoid cartilage: /, rima 
glottidis; m, facet for inferior cornu 
of thyroid cartilage. 



752 



THE LARYNX. 



require prolonged rest. Should a patient, in the face of such advice, 
insist upon an attempt to fulfill the engagement, it becomes impera- 
tive to afford him as much aid as is possible while so doing. To 
this end Watson Williams advises strychnia, gr. % , administered 
by hypodermatic, and twenty minutes preceding the engagement 
to atomize the throat with deep inhalations of a solution composed 
of the following : — 



IJ Menthol 

Morph. sulph. 
Cocainse hydrochl. 



gr. vj. 

gr. ss. 
gr. ij. 



Acidi oleici ff|.xv. 



Olei vaselini 



3ss. 



A small amount of a 1 : 5000 solution of adrenalin chlorid 
sprayed directly into the larynx produces contraction of the tis- 
sues without ill effects. During the engagement the codeia loz- 
enge above mentioned may be allowed to dissolve in the mouth. 
Patients are sometimes temporarily benefited by the employment 




Fig. 493. — The intratracheal cannula and syring 



of mild astringents. A spray of chlorid of zinc, 10 grains to the 
ounce of water, is usually employed when an astringent is indi- 
cated. An intratracheal injection (Fig. 493) of a 2 per cent, solution 
of camphor and menthol in benzoinol, at least ten minutes previous 
to singing or speaking, gives much relief and is of material aid to 
the voice. Intratracheal injections employed three or four times 
daily produce great relief of the distressing dry cough and laryn- 
geal irritation. The injection should be carried into the larynx 
through a long curved cannula attached to a syringe. The patient 
withdraws the tongue and the surgeon introduces the laryngeal 
mirror, and, as soon as he obtains a view of the interior of the larynx, 
the cannula is guided into position. The patient is then instructed 
to inhale and the remedy is slowly instilled into the larynx. The 
smarting and discomfort is momentary, and it is followed by 
immediate relief. 

When hemorrhage occurs the patient should be placed in bed 
and the larynx carefully sprayed with a 1 : 5000 solution of adrenalin 
chlorid, an ice-coil should be placed upon the neck and ice admin- 
istered by the mouth. Edema is a rare occurrence in uncomplicated 
simple acute laryngitis. Should it occur, prompt surgical inter- 
ference becomes necessary and the edematous tissue must be incised 
after the manner described for cedema glottidis (page 757). 



ACUTE INFLAMMATORY DISEASES. 753 



SIMPLE ACUTE LARYNGITIS IN CHILDREN. 

Synonyms. — Spasmodic croup ; spasmodic laryngitis ; false 
croup; laryngitis stridulosa. 

In young children from one to five years of age simple acute 
laryngitis is more serious, owing to the smaller calibre of the 
larynx and the comparatively greater amount of intralaryngeal 
swelling. These give rise to additional symptoms of extreme dysp- 
nea, with stridulous respiration. Trie temperature is higher than 
in adults, often reaching 104° to 105°, and the dry. metallic cough 
may be accompanied by alarming embarrassment of respiration. 
The paroxysms are usually nocturnal and are aggravated by the 
accumulations of thickened mucus which are retained during sleep. 

Enlarged tonsils and adenoids strongly predispose to the^ 
attacks. 

Symptoms. — The spasmodic attack is usually preceded by a 
day or two of hoarseness and a croupy cough, during which the 
child is cross and restless, and the skin is dry and hot. The 
typical paroxysm comes on during the early part of the night, when 
the child awakes suddenly with alarming dyspnea, stridulous 
breathing and a frantic struggle for air which continues without 
abate until the retained secretions are dislodged. Recurrence may 
take place several times during the night, and the attacks may be 
expected to recur for at least three nights. 

Diagnosis. — The diagnosis is based upon the absence of the 
typical symptoms of diphtheria, membranous laryngitis, pressure 
from neoplasms, abscesses, or glandular enlargement in the imme- 
diate vicinity. 

Treatment. — Laryngitis, even in slight form, occurring in 
infants calls for prompt measures in order that the nocturnal 
paroxysms of croup may be prevented. A brisk cathartic, castor- 
oil preferred, rest in bed and the employment of steam inhalations, 
medicated with compound tincture of benzoinol, a dram to the pint 
of water, administered under a tent ; hot fomentations applied to 
the neck and brisk rubbing of the neck and chest with camphorated 
oil, are the remedies usually employed. For internal medication 
the following expectorant formula is recommended by Parker : — 

I£ Vini ipecacuanha in ij. 

Solution of ammonium acetate rn,xv. 

Ammonium carbonate gr. ss. 

Syrup of Tolu tii . x. 

Aquas q. s. ad 3j. 

M. Sig. : Every four hours. 

Minute doses of codeine, gr. % every three hours, for a child 
of three years of age, may be given when the cough is severe and 
the child sleepless therefrom. Bosworth administers codeine in the 
following formula : — 

48 



754 THE LARYNX. 

R Dilute hydrocyanic acid tt\, i j . 

Codeine gr. its. 

Carbonate of ammonium gr. xv. 

Cherry laurel water q. s. ad 3ij. 

M. Sig. : A teaspoonful every two hours to a child of seven years, and 
less in proportion for younger children. 

The nose should be kept free from accumulated secretion by 
spraying with an alkaline solution. For the paroxysm a hot 
mustard bath composed of 1 dram of mustard to the gallon of 
water, at a temperature of from 100° to 110° F., may be given with 
much benefit. The child should remain immersed in this solution 
for eight or ten minutes and then be wrapped in blankets and placed 
in bed underneath a tent in which a steam kettle is in constant 
use. If emesis can be induced the relief will more quickly ensue. 
This may be accomplished by tickling the patient's fauces with the 
finger. The administration of emetics is slower in action and often 
induces severe indigestion, which may persist for several days. 

It may here be stated that measures so serious as tracheotomy 
and intubation are rarely required for the relief of the paroxysms 
of spasmodic croup. Should the symptoms remain obdurate and 
emesis imperatively demanded, a dose of one dram of the wine of 
ipecacuanha, or sulphate of zinc, grs. 10 to 20, dissolved in milk, 
should be administered at one dose. 

Subsequent to the attack the child should be examined for 
diseased tonsils and adenoids, placed under proper hygiene sur- 
roundings, and his clothing, diet and habits should be regulated to 
meet the conditions of climate, season of the year and his state of 
health. Children who are free from diseased tonsils and adenoids, 
who are kept much of the time in the open air, and are not "cod- 
dled" or overclothed, especially about the throat, are rarely subject 
to spasmodic croup. 

3. ACUTE INFECTIOUS LARYNGITIS. 

Synonyms. — Acute edematous laryngitis ; cedema glottidis. 

DUE TO GENERAL INFECTIONS. 

Acute infection of the laryngeal mucosa occurring in the course 
of the exanthemata and other specific fevers are described in 
Chapters XXXI and XXXII. 

DUE TO LOCAL INFECTIONS. 

(a) Acute Edematous Laryngitis. 

Acute edematous laryngitis is an acute inflammatory process 
of septic origin, involving the laryngeal mucosa and occurring 
sometimes primarily, but more often in conjunction with patho- 
genic inflammations of nearby structures. The infection may 
involve the mucous membrane alone, the submucous tissues, and 
it may invade the perichondrium of the laryngeal cartilages. In 



ACUTE INFLAMMATORY DISEASES. 755 

the superficial form, wherein the mucous membrane only becomes 
inflamed, the symptoms are similar to those of simple acute laryn- 
gitis, but with a higher range of temperature and longer duration. 
When the infectious process invades the submucous areas the 
attack is characterized by sudden and severe inflammation of the larynx, 
with edema, and distressing dyspnea. 

Etiology. — The excitant is always some form of pathogenic 
micro-organism, of which the streptococcus is the most common. 
It is more common in males and is essentially a disease of middle 
life. The disease rarely occurs as a primary affection, but is second- 
ary to septic tonsillitis, pharyngeal phlegmon, peritonsillar abscess, 



Fig. 494. — The Hays pharyngoscope and laryngoscope. A, First 
position in inserting the instrument. B, The pharyngoscope in place 
with the mouth closed. (Hays, with permission.) 

erysipelas, or angina Ludovici. Systemic affections, especially the 
specific fevers, diabetes, B right's disease or alcoholism, are con- 
tributing factors. 

Pathology. — Primarily the attack induces rapid and severe 
inflammatory changes in which the laryngeal mucosa becomes 
intensely congested, swollen and infiltrated with serous exudate. 
Edema rapidly supervenes and may involve the entire larynx, but 
it is usually confined to the epiglottis and the tissues surrounding 
the arytenoids. As the edema increases, the epiglottis entirely loses 
its normal outlines and becomes a large, bulbous mass (Fig. 496). 
In like manner the mucosa in the region of the arytenoids may 
become edematous. Subglottic edema is rare except in the severest 
cases. The process usually resolves without tissue necrosis, but 
severe cases are likely to terminate in large sloughs or abscesses. 

Symptoms. — The symptoms are somewhat varied. In mild 



756 



THE LARYNX. 



cases the patients complain of sore throat, with dryness and full- 
ness. As soon as the epiglottis becomes congested, dysphagia 
appears, while, with the development of edema, dyspnea may be 
expected. Mild cases with low temperature and little edema are 
unaccompanied by severe symptoms, except some hoarseness and 
hawking attempts to relieve the sensation of fullness. When the 
disease is more severe it is ushered in by rigors, moderate rise of 
temperature, and intense pain and discomfort in the larynx, par- 
tially from inflammation and partially from pressure. This is 
accompanied with dysphagia and often urgent dyspnea, which in 
many patients produces a fear of impending suffocation. For about 
thirty-six hours the symptoms continue to increase in severity, 
after which the crisis may be expected. When abscess develops 
there is no definite time of crisis and all symptoms may be alarming 




Fig. 495. — The Tobold concealed laryngeal scarifier 



for several days, during which the temperature curve will indicate 
sepsis, and pain will be severe. This affection occurring in weak- 
ened individuals who have diabetes or Bright's disease, or during 
convalescence from any of the infectious fevers, or when compli- 
cated with general infection of the upper air passages, leads to other 
and more alarming symptoms and complications, the chief of which 
are great prostration, septic pneumonia and extreme dyspnea. A 
fatal issue sometimes ensues from exhaustion or cardiac failure. 

Diagnosis. — Examination of the larynx either by the laryngeal 
mirror or by the Hays pharyngoscope (Figs. 19 and 494) reveals 
intense engorgement and edema. This condition in a patient giving 
a history of dyspnea, dysphagia and severe, irritating cough of short 
duration is sufficient to establish a diagnosis. It may be confounded 
with foreign bodies, traumatism, burns and scalds, or with cancer, syph- 
ilis and tuberculosis. 

Prognosis. — In the simpler cases, under proper treatment, the 
prognosis is good. Death may occur from suffocation, exhaustion, 
general sepsis, or from cardiac or pulmonary complications. 

Treatment. — At the onset the patient should be instructed to 
remain in bed in a well-ventilated room of even temperature. 

General Treatment. — The patient's strength should be sus- 
tained by the free use of plain, wholesome, soft diet, consisting of 



ACUTE INFLAMMATORY DISEASES. 757 

meat broths, milk, eggnog, etc. Stimulants are admissible, espe- 
cially after symptoms of exhaustion appear. The medicinal treat- 
ment should be commenced with a brisk cathartic, calomel pre- 
ferred. If grippe, rheumatism or gout be present, phenacetin and 
salol, in doses of 2 to 3 grs. each, every three hours, or of aspirin, 
5 grs. every four hours, will relieve pain and shorten the duration 
of the disease. Strychnia is often required to sustain the heart. 
Many authors recommend the internal administration of large doses 
of tincture of perchlorid of iron. This drug never has produced 
marked relief in the author's experience, free doses of codeia, from 
34 to 1 gv. every four hours in adults, relieves the cough, pain and 
irritation, and this, in turn, tends to relieve the edema. The bromids 
are beneficial in extreme dyspnea, especially when complicated with 
pulmonary affections or exhaustion (Parker). Semon recommends 
the frequent inhalation of oxygen, provided any pulmonary compli- 
cation arises. 

Local Treatment. — During the early stages relief follows the 
application of the ice-coil to the neck, and the administration 




Fig. 496. — Edema of the epiglottis and arytenoids relieved by incisions. 

of ice by mouth. Spraying the larynx with a 2 per cent, solution 
of cocaine has been extolled and is admissible except to those pos- 
sessed of an idiosyncrasy, or who are exhausted from wasting dis- 
eases. An intratracheal injection (Fig. 493) of a small quantity 
of a solution of suprarenal extract, 1 : 5000, with or without the 
addition of cocaine, is most efficacious and may be applied hourly 
if the symptoms demand. 

The lemon-juice and adrenalin spray (see page 748) applied to 
the swollen and edematous tissues at frequent intervals produces an 
astringent effect and at the same time reduces the swelling. 

Abscesses, wherever located, should be promptly incised. 
Local bloodletting, whether by leeches or incision, is of ques- 
tionable efficacy. Whenever edema occurs, especially with suffi- 
cient severity to cause dyspnea, the edematous tissue should be 
scarified without delay. It is always dangerous to leave a patient 
in this condition unattended by the surgeon, because of the danger 
of suffocation, and a sterile tracheotomy outfit should be at hand 
in case a tracheotomy becomes necessary. 

The operation of scarifying should be preceded by an appli- 
cation of a 10 per cent, solution of cocaine over the edematous 
surfaces. After a delay of ten minutes, with a curved concealed 
laryngeal knife (Fig. 495) the parts most distended should be 



758 THE LARYNX. 

incised to the depth of about 5 millimeters, and 5 to 10 millimeters 
in length (Fig. 496). From two to five such incisions may be made 
at one sitting, with great relief. A free flow of blood and serum 
follows, and in order to prevent it from entering the larynx the 
patient's head should be bent forward and downward. 

Large abscesses are sometimes encountered, the opening of 
which may be followed by alarming suffocation, and immediate 
tracheotomy may become necessary. In those cases wherein the 
edema is general throughout the larynx, tracheotomy (Chapter 
XXXI) offers the only relief. 

Scarification of the tissues should be followed by continuous 
medicated steam inhalations. Occasionally these are not well 
borne. 

MacEwen's suggestion that a soft-rubber catheter be passed 
through the larynx and left in situ until the edema subsides is 
worthy of mention. 

(&) Acute Infectious Perichondritis. 

Etiology. — It is a rare affection in which the bacterial invasion 
of the perichondrium occurs as a complication of acute infectious 
fevers, chiefly typhoid, typhus, diphtheria, erysipelas, and pyemia, 
or from traumatism. 

Pathology. — The disease is usually local and confined to one 
cartilage, awd the infection enters through an abrasion or ulcera- 
tion, or through the blood or lymph channels. The invasion is 
characterized by swelling, inflammation, edema and more or less loss of 
motility. If resolution does not take place the deeper structures be- 
come involved, necrosis of the soft tissue takes place with abscess 
formation, or the necrotic process may invade the cartilage and finally 
result in sloughing, ankylosis, adhesions, laryngeal deformities, and. 
occasionally, stenosis of the larynx. 

Symptoms. — Localized pain in the larynx, moderate fever, and 
chilly sensations are the first symptoms complained of. As the 
disease progresses and the swelling encroaches upon the lumen of 
the larynx, the patient complains of suffocation, the voice becomes 
impaired, and the general appearance is that of extreme anxiety. 
Meanwhile there is no cessation of the pain, and there is marked 
impairment of the movements of the cartilage. The great prostra- 
tion and exhaustion which marks the accumulation of septic prod- 
ucts may be of sufficient severity to cause a fatal issue. In more 
favorable cases, with proper treatment, where the necrosed tissues 
either slough or are removed by surgical means, and where the 
abscesses are freely opened and properly drained, recovery is the 
rule. 

Diagnosis. — The diagnosis is based upon the appearance and 
the history of localized pain, fever and abscess. The condition should 
be differentiated from chronic perichondritis (syphilitic, tuberculous, 
cancerous). 

Prognosis. — The majority of patients recover, but troublesome 



ACUTE INFLAMMATORY DISEASES. 759 

sequelae in the form of impairment of the voice and partial laryngeal 
stenosis may persist through life. 

Treatment. — The general and local treatment is similar to that 
for acute edematous laryngitis heretofore described. All phonation 
must be prohibited except by whispering. In advanced cases 
surgical measures furnish the only means for relief. The edema- 
tous tissue within the larynx should be incised at several points, 
under cocaine anesthesia, using for this purpose the curved, concealed 
laryngeal knife (Fig. 495). In a similar manner abscesses should be 
evacuated. When the swelling fluctuates externally, free incision 
should be made through the skin and down to the seat of the disease, in 
the cartilage. If possible this operation should be done under local 
anesthesia. 

Alarming dyspnea calls for prompt tracheotomy unless relief 
is obtained by an intralaryngeal injection (Fig. 493) of a mixture 
containing cocaine, 4 per cent., and adrenalin, 1 : 5000, or the astrin- 
gent spray (page 748). Parker recommends the following: — 

ty Potassii iodidi gr. xv. 

Ammonia carbonat gr. iij. 

Ferri citratis et ammonia gr. x. 

Aqtue q. s. ad f j. 

(c) Membranous Laryngitis. 

Synonyms. — Membranous croup ; croupous laryngitis ; pseudo- 
membranous croup; diphtheritic laryngito; idiopathic membranous 
croup ; true croup. 

There are two general varieties of membranous laryngitis, 
viz., the diphtheritic and the non-diphtheritic. The former (laryngeal 
diphtheria) is fully described in Chapter XXXI, and is a separate 
and distinct affection from the type which is herein defined. In 
each there is an obstructive inflammation of the laryngeal mucosa, 
with an outpouring of fibrinous exudate. 

Membranous laryngitis is idiopathic, non-contagious and non- 
communicable ; it is local in its course and the membrane is con- 
fined to the laryngeal region. The Klebs-Loeffler bacillus is never 
found, and it does not terminate in paralysis or renal complications. 

Etiology. — Lowered resistance from any cause predisposes to 
this affection. The disease is rare, occurs only in childhood, and 
is not common after the seventh year. It is often difficult to deter- 
mine the exciting cause, but it is known that the affection may 
be induced by applications or inhalations of irritants, burns and 
scalds from inhalations of steam or smoke, caustics accidentally 
applied, or traumatism from cuts, falls and fractures. There is con- 
siderable evidence that the disease develops secondarily to scarlet fever, 
small-pox, pneumonia, and other virulent infections, especially the 
streptococcus. 

Pathology. — The characteristic pathological alteration is the 
appearance of a true fibrinous membrane on the laryngeal mucosa 
similar in appearance to that of diphtheria, but without the Klebs- 
Loeffler bacillus. The exudate is fibrinous and is located upon the 



760 THE LARYNX. 

epiglottis, arytenoid cartilages, and ventricular bands, often extending 
into the subglottic space. Occurring in children, it is difficult to inspect 
the larynx and watch the development of the membrane. The exudate 
is yellowish, less adherent than in diphtheria, and does not penetrate as 
deeply into the mucosa as the lesion of the diphtheria. 

Symptoms. — There are no prodromal symptoms. The disease 
comes on suddenly and at the commencement there is hoarseness 
of a peculiarly metallic quality, associated with some malaise and 
rise of temperature. Cough soon ensues and is low-pitched, metallic 
and extremely croupy in character. In severe cases dyspnea, 
dysphagia and finally complete aphonia are among the early symp- 
toms. Dyspnea is a continuous and often an alarming symptom. Its 
onset is gradual and it is characterized by stridulous, crowing noises, 
both with inspiration and expiration, and it produces the clinical picture 
of impending suffocation. 

Whenever portions of the membrane come away as the result 
of paroxysms of coughing or from medication, the symptoms par- 
tially subside. During the paroxysms there is extreme restlessness, 
cyanosis, the head is thrown backward, and usually abdominal 
recession occurs with each respiratory act. Unless relieved by expul- 
sion of membrane, by tracheotomy (Fig. 299) or by intubation 
(Fig. 292), the patient gradually succumbs and death from asphyxiation 
ensues. 

Expulsion of the membrane invariably brings relief. Further- 
more it is a favorable symptom, even though the membrane re-forms. 
In favorable cases the membrane exfoliates spontaneously, and 
after a period of from three to five days the exudate disappears. 
Extension of the membrane and the development of pneumonia are 
unfavorable complications. 

Diagnosis. — The disease may be mistaken for spasmodic croup, 
edema of the larynx, diphtheria, or foreign bodies in the larynx. 
In spasmodic croup there is more pain, the respiratory disturbance 
is less prolonged, and there is no membranous exudate. Laryngeal 
edema, while accompanied by cough and labored respiration, the cough 
is less metallic and usually is moist and accompanied by expectoration. 
Diphtheria (see Chapter XXXI) has many symptoms in common, but 
there is usually a pharyngeal deposit of membrane, a history of con- 
tagion, more constitutional disturbance, and, finally, the bacterial 
examination shows the presence of the Klebs-Loeffler bacillus. Foreign 
bodies in the larynx may cause stridulous respiration and cough, but 
it is less metallic, less hoarse, there is no fever and a change in the 
position of the patient's body often causes a change in the character 
of the symptoms. 

Prognosis. — The prognosis is always grave. In fatal cases 
death results from immediate suffocation, carbonic acid poisoning 
(asthenia), or pulmonary complications. Intubation has materially 
lowered the death rate. 

Treatment. — During the early stages, previous to the formation 
of the membranous exudate, all measures heretofore recommended 
for acute laryngitis in children should be employed. In addition, 



ACUTE INFLAMMATORY' DISEASES. 761 

the patient should be kept in a warm, well-ventilated room, the 
atmosphere of which is constantly charged with steam. The steam 
may be generated from several "croup kettles" (Fig. 497) in the 
absence of a stove. If necessary the patient may be kept under- 
neath a tent surcharged with steam, and with only a small opening 
for ventilation. Relief is sometimes obtained from impregnating the 
steam with camphor or menthol. Steam impregnated with unslaked 
lime has been advocated for inhalations. It is generated by placing a 
large lump of lime in a wooden bucket containing four or five quarts of 
boiling water. The effect of the menthol may also be obtained by 




Fig. 497. — Croup kettle or steam 



burning crystals in a spoon or other receptacle over a flame. These 
remedies are all employed for the purpose of decreasing and dislodging 
the membranous exudate. 

Emetics sometimes afford temporary relief but they are 
extremely depressing. Wine of ipecacuanha is effective for this pur- 
pose. Calomel is a most efficacious remedy for the relief of the urgent 
symptoms of membranous laryngitis. At the commencement of the 
disease a liberal dose should be administered internally. Calomel 
inhalations also produce marked relief of the dyspnea. The method of 
employment is as follows: With the patient underneath a tent, the 
fumigations should he administered every two hours, by subliming 5 to 
20 grains of calomel. After one day the intervals may he prolonged, 
providing relief has been obtained; otherwise, the calomel sublimations 
should be abandoned. Should the dyspnea increase, threatening suffo- 
cation, in spite of all efforts to relieve by general and local treatment, 
tracheotomv or intubation should immediately he resorted to. before the 



762 THE LARYNX. 

symptoms of exhaustion have appeared. Intubation skillfully per- 
formed is preferable and gives better results. 

4. ACUTE LARYNGITIS DUE TO TRAUMATISM. 

Etiology. — Acute laryngitis of traumatic origin is similar to 
ordinary acute laryngitis unless infection ensues. The following acci- 
dents or injuries are among the etiological factors : The inhalation of 
irritating gases or steam fumes ; the inhalation of foreign bodies ; 
the injuries which result from swallowing rough or jagged bodies; 
the intralaryngeal application of caustics; rupture of blood-vessels; 
external injuries from blows, strangling or cut-throat. 

Symptoms. — The symptoms vary with the cause and extent 
of the injury. When this is slight and no sepsis supervenes, the wounds 
will heal promptly and there is only slight discomfort. When the area 
of injury is extensive, as from scalds or corrosive poisons, the inflam- 
mation is prone to induce edema and great discomfort results. When 
infection ensues, abscesses are likely to form, and the large sloughs 
which may form sometimes eventuate in gangrene. 

Treatment. — The treatment for acute laryngeal inflammations 
and for acute edema is described under the appropriate headings. 
When the laryngeal lesion is due to foreign bodies, cut-throat, 
fractures or other injuries, prompt surgical measures are indicated. 



CHAPTER XLIX. 
CHRONIC INFLAMMATORY AFFECTIONS OF THE LARYNX. 



1. CHRONIC HYPERPLASTIC LARYNGITIS. 

It is convenient to study this subject under the following head- 
ings, which are based largely upon the clinical manifestations : 1, simple 
chronic catarrhal (diffuse) laryngitis ; 2, chronic subglottic laryn- 
gitis; 3, pacchyderma laryngis ; 4, chorditis nodosa (singers' nodes). 

Following the plan adopted by Parker, in order to avoid need- 
less repetition, the etiology, symptoms, diagnosis, prognosis and 
general treatment of the various types are considered together. 
Following this, a detailed description of the distinctive characteris- 
tics of each type will receive consideration. 

Etiology. — Chronic laryngitis is rarely, if ever, a primary 
affection. It occurs chiefly as a result of a succession of acute 
inflammations, either of the entire upper respiratory tract, or of the 
laryngeal mucosa alone. These attacks are superinduced by a 
series of contributing causes which act both directly and indirectly. 

Contributing Causes. — Among the contributing causes are nasal 
stenosis, which gives rise to mouth-breathing, and robs the inspired 
air of the sifting and moistening process ordinarily furnished by the 
nasal erectile tissue. The purulent and otherwise unhealthy secretions 
emanating from purulent affections of the nasal accessory sinuses, from 
chronic pharyngitis, from chronic lacunar tonsillitis, and from specific 
ulcerations, accumulate about the laryngeal orifice and thereby 
induce severe local irritation. In order to relieve this, the patient 
almost constantly coughs and hawks in his effort to dislodge the 
retained secretion, and this act tends to produce intralaryngeal 
congestion. 

Laryngeal inflammation associated with acute infections, 
especially grippe, may be sufficiently serious and deep seated to 
become chronic. Prolonged sojourn in damp, cold atmospheres, or 
in air laden with smoke, dust, irritant fumes, etc., is extremely 
deleterious to the laryngeal membranes. 

Chronic laryngitis is common in alcoholics, excessive smokers 
and certain occupations. Thus smokers, street cleaners, cigar, 
snuff, wood, stone, metal, and chemical workers become easy 
victims. 

Exacerbations of laryngeal inflammation are more common in 
damp climates and during the winter months. 

Another common cause is overuse or faulty production of trie 
voice, observable in public speakers, singers, and hucksters. In 
singers this may produce nodes upon the vocal cords, while violent 
efforts at speaking or screaming by one whose laryngeal membranes 

(763) 



764 THE LARYNX. 

are already inflamed and engorged, may cause rupture of small 
vessels in the submucosa and give rise to a condition which is 
generally termed hemorrhagic laryngitis. 

Chronic laryngitis, in common with a general relaxed and 
inflamed condition of the mucosa and muscles of the upper respira- 
tory tract, may be induced by gastric and intestinal disorders. It 
also occurs in individuals who are victims of gout, rheumatism, 
anemia and cardiac disease. It is often associated with chronic 
pulmonary diseases, notably tuberculosis, chronic bronchitis, 
asthma and emphysema, in which it is aggravated by the accom- 
panying cough. 

A further contributing cause is found in new growths and 
chronic lesions about the throat, neck and thorax, lupus and syphilis. 

It is essentially a disease of adult life, and is more common in 
males probably on account of occupation. The excessive use of 
tobacco is also often a contributing cause. 

Symptoms. — The objective symptoms are pathological and need 
not be defined here. The subjective symptoms are referred chiefly 
to the alterations in the voice and to changes in the quality and 
character of the secretions. 

The symptoms which particularly refer to the voice are "tired 
voice," aphonia, and "breaks" during phonation. Hoarseness is 
most marked during the early morning hours, but the voice usually 
becomes more clear as the day progresses unless it is overused. 
Forced speaking, however, becomes difficult and often impossible, 
and any prolonged vocal effort will give rise to a sensation of 
tickling and often strangling cough, to relieve which speakers 
resort to the frequent drinking of water. 

In singers the voice can never be depended upon ; it breaks or 
tires quickly, vocal efforts require forced muscular strain and pro- 
duce more or less pain within the larynx. There is a sensation of 
dryness and irritation in the larynx, and a constant, though not 
increased, exudate of thick, mucopurulent secretion. In severe cases 
with extensive infiltration in the submucosa there may be complete 
aphonia for considerable periods. There is an almost constant desire 
to relieve the dryness, the irritability and the accumulated secretions by 
hawking or coughing. 

The secretions are mucopurulent, often scanty, and laden with 
particles of dust or other debris significant of the patient's occupa- 
tion. Excessive secretion is rare, and when present should lead to 
a careful examination of the trachea, bronchi and lungs. 

Diagnosis. — The diagnosis, never difficult, is based upon the 
alterations in the voice, the changes in the laryngeal mucosa, the 
scanty but thick secretion, and the history of exacerbations of acute 
laryngitis. 

Prognosis. — Aside from the greater susceptibility to acute 
infections and to local complications, syphilis and tuberculosis, the 
danger to life is slight. In simple cases wherein the structural 
changes are slight the disease is curable, providing the underlying 
cause can be discovered and removed. When the hyperplasia has 



CHRONIC INFLAMMATORY AFFECTIONS. 765 

extended over large areas the prognosis as to final recovery is less 
favorable. In these it is often possible to relieve the aggravating 
symptoms, except in advanced pacchyderma, where only partial 
recovery may be expected. In singers and public speakers a 
guarded diagnosis should be given regarding the full recovery of 
the staying qualities of the voice. 

General Treatment. — To discover and eradicate the underlying 
cause is the first essential in the treatment. Predisposing and con- 
tributing factors also should be outlined and given due considera- 
tion. If the disease has resulted from a succession of attacks of 
acute laryngitis, a rigid enforcement of the means of prevention, 
such as have been outlined for acute rhinitis (Chapter XXXIII), should 
be inaugurated. Obstructive lesions within the nose and nasopharynx 
must be removed by appropriate operative procedures, in accord- 
ance with the rules laid down in the chapters on the nose, naso- 
pharynx and pharynx. Pulmonary, cardiac, gouty, and rheumatic 
affections and anemia should be relieved by appropriate measures. 

When due to faulty production or misuse of the voice, com- 
plete rest should be maintained for a considerable period of time, 
and followed by the adoption of a correct method of training, under the 
guidance of an experienced teacher. 

The excessive use of alcohol and tobacco should be prohibited, 
and hazardous occupations should be changed to those with more 
wholesome surroundings. 

If associated with evidences of tertiary syphilis or tuberculosis, 
these diseases should receive appropriate treatment (see Chapters 
XXIX and XXX). It is of the utmost importance that patients 
suffering from chronic laryngitis should have proper physical exer- 
cise, preferably in the open air, with fresh air even during sleep, 
and that they should avoid sedentary habits or occupations. 

A full diet of plain foods minus spices and condiments should 
be given, the bowels to be properly regulated by morning doses of 
laxative salts for several days at a time, and if necessary an occa- 
sional active cathartic. 



SIMPLE CHRONIC CATARRHAL (DIFFUSE) LARYNGITIS. 

Pathology. — The pathological changes are varied, depending upon 
the primary cause of the affection. Hyperemia is constant, and is 
associated with variations in the thickening (hyperplasia) of the 
mucous membrane and submucosa. When the process is con- 
tinuous and the inflammatory changes slow, there is a gradual pro- 
liferation of exudate into the submucosa and involvement of the 
glandular and connective tissue. In other cases there is engorge- 
ment and final dilatation of the blood-vessels, which causes suffi- 
cient perivascular pressure to produce thickening in the mucosa. 
In many cases the thickening is slight, although it may be quite general 
throughout the larynx. Certain locations, chiefly the interarytenoid 
space and the vocal cords, are the seat of congestion and thickening. 
The cords lose their distinct outlines and lustre, and become thickened 



766 THE LARYNX. 

and of pinkish or decidedly red color, traversed by a network of dilated 
superficial vessels (Fig. 49S). The interarytenoid space, ventricular 
bands, and rarely the cords become the seat of extensive submucous 
infiltration, which gradually encroaches upon the epithelium, producing 
roughness and induration. In a limited proportion of cases the infiltra- 
tion extends even beyond the submucosa into the muscles, causing loss 
of motion of one or both vocal cords. 

Local Treatment. — The topical application of remedial agents 
is accomplished by means of sprays, injections (Fig. 493), inhala- 
tions (Fig. 497), direct applications with the cotton carrier (Fig. 
432), and insufflations. With our modern armamentarium these 
are applied for cleansing, astringent, stimulating, sedative, and 
tonic purposes. Each treatment should be inaugurated by cleaning 
the membranes of all secretions. For this purpose a detergent spray 
solution consisting of sodium bicarbonate, potassium bicarbonate, 
each 10 grains to the ounce of water, or a normal salt solution, or 
the inhalations of steam, may be employed. The spray tip must 




Fig. 498. — Inflamed and thickened vocal cords. 

have a downward curve at right angles, and be carried well back 
behind the epiglottis before the pressure is applied. 

It is true that the spray solution as ordinarily used is largely 
condensed upon the pharyngeal walls, but, when thrown directly 
into the larynx by drawing the tongue forward, a small portion of 
the solution enters. 

Mild astringent solutions, like chlorid of zinc, 15 to 30 grs. to the 
ounce, sulphate of copper, 5 to 20 grs. to the ounce, perchlorid of iron, 
30 to 90 grs. to the ounce, may be applied by cotton applicator. Nitrate 
of silver, 10 to 60 grs. to the ounce, may be used in the same manner. 
Perchlorid of iron and nitrate of silver often cause distressing laryngeal 
spasm. To relieve the spasm the patient should be instructed to give a 
succession of short coughs. To avoid laryngeal spasm a preliminary 
application of a 4 per cent, solution of cocaine should be made and the 
surplus solution should be carefully squeezed out of the cotton before 
introducing it into the larynx. Laryngeal irritation and cough are 
greatly relieved by the intratracheal injections heretofore recommended 
for acute laryngitis (Chapter XL VIII). 

Two or three treatments weekly by the surgeon are necessary 
for the purpose of inspection and the application of suitable local 
measures of treatment. Ichthyol locally applied in the following 
formula, after thorough cleansing, has given excellent results on 
account of its stimulating and somewhat astringent qualities : — 



CHRONIC INFLAMMATORY AFFECTIONS. 767 

R Ichthyol, 

Glycerini aa 3ij. 

Aquas q . s . a d 3j. 

The author's laryngeal applicator (Fig-. 432) is made of silver, 
the distal end being sufficiently flexible to admit of being shaped 
to suit the individual case. It is important to. wet the tip and to wind 
the cotton well up from the tip in order to prevent slipping, while 
at the distal end it should be loose and brush-shaped. In case the 
trachea also is involved the method of treatment by intratracheal 
injections is most efficacious. 

It is sometimes necessary to train patients to submit to this treat- 
ment, and for two or three times a previous application of cocaine may 
be necessary. The more slowly the solution is injected and the deeper 
the inhalations, with wide-open cords, the more thorough the applica- 
tion will be. Some burning and cough immediately follow, but the 
ultimate relief is often magical. 

In cases of paralysis of the muscles resulting from deep-seated 
infiltration the faradic or high-frequency current may be employed 
with benefit. 

CHRONIC SUBGLOTTIC LARYNGITIS. 

In this variety there is infiltration in the subglottic tissues, 
often accompanied by hoarseness and dyspnea. The swelling 
undoubtedly results from simple chronic inflammation, which should 
not be confounded with rhinoscleroma, tuberculosis, syphilis or 
malignancy. 

Pathology. — The pathological changes consist of inflammatory 
hyperplastic thickening in the subglottic mucosa. The infiltration is 
usually deep-seated, and the affection often occurs as a complication of 
chronic hyperplastic laryngitis. 

Symptoms. — The ordinary symptoms of chronic laryngitis are 
supplemented by serious dyspnea and marked impairment of the 
voice. The latter becomes muffled and aphonic. Effort to dislodge 
the secretion is best described as a single, short, barking, metallic 
cough, similar to that observed in aneurism or tumor compression upon 
the trachea. The dyspnea is often sufficiently profound to induce all 
the phenomena of impending suffocation. 

Examination of the larynx reveals the oval masses below the 
cords, which encroach upon the lumen of the glottis. During pho- 
nation the cords do not fully respond, either in motion, vibration or 
approximation. The infiltration is softer than in rhinoscleroma (Chap- 
ter XXXII), a rare disease which usually affects the nasal cavities as 
well as the larynx. The exact nature of the swelling may remain 
indeterminable until a microscopic examination has been made. 

Prognosis. — The prognosis is more grave than in other forms 
of diffuse laryngitis. The hoarseness remains permanent, even 
though the swellings partially subside or arc removed, and the 
alarming dyspnea may necessitate tracheotomy at any moment. 

Treatment. — Authors very generally recommend the liberal 
administration of iodid of potassium, in doses of from 10 to 20 



768 THE LARYNX. 

grains, three times a day, as the most effective absorbent. The 
dosage should depend upon the patient's ability to take this drug. 
If a tonic is required the syrup of the iodid of iron freshly made, 
in doses of from 10 to 30 minims, thrice daily, is beneficial. Caustics 
are of doubtful benefit, but applications of a 50 per cent, solution of 
lactic acid, of trichloracetic acid, or of nitrate of silver, 30 to 60 grs. 
to the ounce, when carefully made, may reduce the area of swelling. 
Great caution should be exercised, when applying caustics or the 
galva'nocautery, not to touch the surrounding tissues, and it should 
be remembered that their use may be followed by reactionary 
swelling and edema sufficient to cause suffocation. It is usually 
necessary to train the larynx at repeated sittings by introducing 
various instruments, in order to accustom this sensitive organ to 
manipulation, and always under cocaine anesthesia. Tuerck's con- 
cealed applicator for applying caustics is the safer method. Crystals 
of nitrate of silver or chromic acid fused upon this applicator are 
among the safest cauterants to be applied, the caustic being con- 
cealed until the growth has been reached. 

In case of impending suffocation, or when permanent stenosis 
has taken place, intubation or tracheotomy becomes imperative. Of 
these the intubation tube is more comfortable and less conspicuous. 
Furthermore, in rare instances, the pressure exerted by the tube 
produces permanent recession and absorption of the growth. As a 
rule, however, a tracheotomy tube or intubation tube, when once 
introduced, must be worn for life. 



PACHYDERMIA LARYNGIS. 

Advanced cases of chronic laryngitis sometimes undergo 
peculiar pathological changes in certain limited areas of the laryn- 
geal mucosa, which give rise to a condition known as pachydermia 
laryngis. The special characteristics of pachydermia laryngis con- 
sist of changes in the epithelium from the normal to the stratified 
variety. During this process the superficial epithelial cells become 
the seat of keratinous deposits. The excrescences thus formed are 
indurated and nodular, and they appear upon the vocal cords or 
interarytenoid spaces. It is more common in males, and occurs in 
middle adult life. It is commonly found in chronic alcoholics, smokers, 
hucksters,.. and sometimes in those who strain the voice or speak for 
long periods in a vitiated atmosphere, or who are obliged to inhale 
irritating gases or dust for long periods. 

Symptoms. — The chief symptom is hoarseness. Dyspnea is 
never severe. On the vocal cords the small nodules appear as 
indurated conical excrescences, and there is usually a corresponding 
depression upon the opposite cord. In the interarytenoid space the 
excrescence is more variable in size, shape and thickness. 

The disease should be differentiated from singers' nodes (Fig. 
499), which are softer, more superficial and unaccompanied by 
induration of the deeper structures. The crust formations of laryn- 
gitis sicca are darker colored and easily removed. 



CHRONIC INFLAMMATORY AFFECTIONS. 769 

Treatment. — Faulty habits must be abandoned, the chronic 
laryngitis must receive due attention (see Treatment of Simple Acute 
Laryngitis), and the hygienic surroundings must be improved. Re- 
moval of the growths may be attempted whenever they are accessible. 
Likewise, cauterants (chromic acid, trichloracetic acid, etc.) may be 
employed. 

Unfortunately, recurrence is common. Complete rest of the 
voice for a long period is most beneficial. 

CHORDITIS NODOSA. 

Synonyms. — Singers' nodules ; trachoma of the vocal cords ; 
chorditis tuberosa. 

Chorditis nodosa, or singers' nodules, is a form of chronic laryn- 
gitis which is characterized by the formation of one or more new 
epithelial growths (nodules) upon the free border of the vocal 
cord. The favorite location for these growths is at the junction of 




Fig. 499. — Singers' nodules upon the vocal cords. 

the middle and anterior thirds. The nodules are small, oval-shaped, 
and occur either singly or multiple. 

Etiology. — It is generally conceded that nodules occur in individ- 
uals who are victims of long-continued laryngitis, and who at the same 
time have used faulty methods of voice production. Hence, singers and 
public speakers, hucksters, etc., are peculiarly liable to this affection. 
Miller claims that the majority of singers' nodes are due to chronic 
lacunar tonsillitis. 

Pathology. — The nodes are composed of stratified epithelium. 
They generally appear upon the free edge of the cord (Fig. 499), 
and are rarely larger than a small bead. They are pinkish white in 
color. The surrounding superficial area of mucosa is usually the seat 
of congestion. 

Symptoms. — The characteristic symptom of this affection is 
impairment of voice and especially a loss of voice control. This 
is illustrated by inability to "strike" certain notes and to sustain 
tones. There is also a tendency for the voice to "crack" or "break" 
during sustained vocalization. 

Upon examination with the laryngeal mirror ( Fig. 19) or the 
pharyngoscope (Fig. 494) the small characteristic pinkish nodules 
projecting from the free border of the vocal cord are observed | Fig. 
499). When two or more nodes are present the mobility of the 
cords may be slightly impaired. 

49 



770 



THE LARYNX. 



Prognosis. — In patients who are willing to submit to a pro- 
longed rest of the voice and then to acquire correct methods of 
voice production the prognosis is favorable. 

Treatment. — The treatment described above for simple chronic 
laryngitis should be adopted. When the nodules are of small size and 
recent development they usually disappear in response to a prolonged 
period of complete rest of the voice. Nodules of larger size should be 
surgically removed. They are removed intralaryngeally under cocaine 
anesthesia. The laryngeal forceps (Fig. 500) is an ideal instrument 
for the removal of singers' nodules. Grant's laryngeal forceps (Fig. 
501) also are useful and safe for this purpose. 

The nodules are prone to reappear after removal, particularly 
if the patient persists in the misuse of his voice. The denuded 




Fig. 5@0. — Various laryngeal for- 
ceps from the models of Frankel, 
Scheinmann, Krause, etc., adjust- 
able to a universal handle. 



surface should be treated daily with a 25 per cent, solution of argyrol or 
a 3 per cent, solution of chlorid of zinc until healed. 

The vocal exercises devised by Curtis and the manipulations 
recommended by Miller produce excellent results. 



2. CHRONIC ATROPHIC LARYNGITIS. 

Synonyms. — Laryngitis sicca ; dry laryngitis ; ozsena laryngis. 

The term laryngitis sicca signifies a symptom, the characteristic 
feature of which is the accumulation and retention of inspissated 
secretions in the larynx. 

Etiology and Pathology. — The etiology and pathology are pre- 
cisely the same as in atrophic rhinitis (Chapter XXXIV"), of which it is 
usually a secondary development. The affection is less common in the 
larynx than in the nasal cavities. The fetid form is invariably 
secondary to that of fetid rhinitis. This affection is aggravated by 
enforced mouth-breathing, and anemia is a common and persistent 
accompanying condition. 

Symptoms. — The chief symptom is the accumulation of masses 
of inspissated crusts within the larynx. Hoarseness and even 
aphonia are present, especially in the morning, persisting until the 



CHRONIC INFLAMMATORY AFFECTIONS. 



771 



crusts are expelled. There is an irritating sensation of dryness in 
the larynx, which the patient endeavors to relieve by violent hawk- 
ing efforts, which often induce strangling and slight hemorrhage. The 
discomfort is aggravated by public speaking or singing. In the fetid 
variety there is a carrion-like stench to the breath. In all cases there 
is diminished secretion. Similar crusty formations are usually found 
in the pharynx, nose and trachea. Pain is absent except during attacks 
of acute inflammation. 

Diagnosis. — The diagnosis is never difficult, and is based upon 
the characteristic accumulation and retention of inspissated 
secretion. 




Fig. 501. — Dundas Grant's 
laryngeal forceps. 



Prognosis. — The disease is very chronic, but when correctly 
treated for long periods of time the persistent accumulation of 
crusts may be arrested, especially when the atrophy and glandular 
destruction is limited. 

Treatment. — Attention should first be directed to the treat- 
ment of the nose and nasopharynx already described, and especially to 
that of chronic purulent affections of the nasal accessory sinuses, 
together with such general treatment as the individual case may require. 
The anemia is indicative of impoverished blood resulting from some 
systemic infection or lack of proper oxygenation. Proper hygienic 
measures, therefore, should be inaugurated. Outdoor exercise, full 
but simple diet, and tonics are essential. The disease, except in 
advanced cases, is usually less marked in the larynx than in the nose 
and pharynx. Proper treatment of the latter favorably influences 
the laryngeal condition. In the simple form there is usually con- 
siderable inflammation of the mucosa and the disease occurs in 



772 THE LARYNX. 

those who use alcohol or tobacco to excess, or who live in dust- and 
smoke-laden atmospheres. Obviously, these pernicious habits 
should be abandoned, and if possible the occupation changed. 

Removal of the crusts is hastened by sprays of non-irritating 
alkaline solutions. It is often necessary to make use of the cotton- 
tipped probe in dislodging crusts, a procedure which many patients 
tolerate after a period of training. After removal of the crusts the 
membrane should be thoroughly swabbed with ichthyol, 25 per cent., or 
Mandl's solution No. 2 (page 514). The intratracheal injections of the 
medicated oily solutions described above are ideal applications for this 
affection. Steam inhalations impregnated with camphomenthol, 2 per 
cent., when the membranes are inflamed and engorged, are soothing. 
In the fetid variety the cleansed intralaryngeal surfaces should be 
swabbed daily with the ichthyol solution. It is important to remove 
all the crusts at least once a day for a prolonged period, especially in 
the fetid variety, and only by so doing is it possible to insure success. 

3. CHRONIC PERICHONDRITIS AND CHONDRITIS. 

Etiology. — Inflammation of the cartilages of the larynx does 
not occur as a primary affection. The disease is induced by infec- 
tion from stab wounds or other traumatisms of the larynx, from 
tuberculosis, syphilis or cancer, from the pressure of intubation 
tubes, and occasionally as a sequela of typhoid fever and diphtheria. 
The superficial swelling and edema often obscure the deep-seated 
inflammation until ulceration takes place, at which time the probe will 
reveal exposed cartilage. In the milder forms no ulceration takes 
place, but instead there is an unusual development of new con- 
nective tissue which gives rise to much thickening. 

Symptoms. — The symptoms are ushered in by gradually in- 
creasing swelling, pain and tenderness about the larynx, with 
dyspnea which is proportionate to the amount of infiltration, and 
obstruction to respiration. In case abscess forms there will be no 
relief until the cavity has been evacuated. Large abscesses are 
liable to encroach both upon the larynx and esophagus, thereby 
inducing dyspnea and dysphagia. The temperature is dependent 
upon the gravity of the infection. When the abscess empties into 
the larynx it is followed by a profuse expectoration of pus, which is 
sometimes tinged with blood. Burrowing abscesses may point at 
some adjacent area of the neck. 

Diagnosis. — Examination under cocaine anesthesia is neces- 
sary, and during the early stages it is often impossible to make an 
accurate diagnosis. The history of syphilis or tuberculosis is con- 
firmatory evidence. When a foreign body is suspected a radiograph 
should be made. There is usually some displacement of the laryn- 
geal structures. 

Prognosis. — The prognosis depends upon the underlying cause. 
In cancer and tuberculosis it is always grave and a fatal issue may 
be expected. 

Treatment. — The treatment depends upon the cause of the 
disease. When due to syphilis, iodid of potash and mercurial 



CHRONIC INFLAMMATORY AFFECTIONS. 773 

inunctions must be vigorously employed. When due to cancer or 
tuberculosis the etiology of the disease must be considered. Surgi- 
cal removal of cancer is the only hope, and this is slight in extrinsic 
cases with lymphatic involvement. When of tuberculous origin both 
local and general measures (see Chapter XXIX) are to be 
employed. Foreign bodies should invariably be removed, the 
method of operating to depend upon the location and size of the 
impacted object. Direct laryngoscopy (Chapter LIII) is an effective 
method for removing foreign bodies from the larynx. 

In suppurative cases the pus should be relieved by incision. 
If the abscess points outward external incision may be made. The 
danger of suffocation from the sudden flow of pus into the larynx 
following intralaryngeal incision may be obviated by immediately 
bending the patient's head and body forward and downward so 
that the pus will flow freely from the mouth. Alarming dyspnea 
at any time during the course of the disease may require immediate 
tracheotomy. 

4. CHRONIC ANKYLOSIS OF THE CRICOARYTENOID 
JOINT. 

In this affection the fixation of the cricoarytenoid joint may be 
partial or complete." It occurs as a result of purulent inflammation 
of the perichondrium of the cartilages, from tertiary syphilis, tuber- 
culous and malignant affections, and from the deposits of gout and 
rheumatism. 

Aphonia is the chief symptom and the. diagnosis is not difficult 
except when the condition is accompanied with marked temporary 
swelling or edema. Partial or complete fixation of the cartilage is 
the basis for diagnosis. 

The affection is not dangerous to life except when bilateral 
fixation in the median line occurs. This requires the permanent 
wearing of a tracheotomy or intubation tube. 

Treatment. — Local treatment is of no avail except as a pre- 
ventive measure. The voice impairment remains permanent. Cic- 
atricial bands may be cut away, and if stenosis ensues intubation 
or tracheotomy may become necessary. 

5. LARYNGEAL STENOSIS. 

The treatment of laryngeal stenosis has been fully described 
under the various headings of acute septic perichondritis, chronic 
perichondritis, ankylosis of the cricoarytenoid joint, acute edema- 
tous laryngitis, membranous laryngitis, and enlarged upon in the 
general chapter on syphilis (Chapter XXX). A few additional 
statements are necessary to complete the subject. 

Stenosis is sometimes congenital in tin- Form of webs which 
extend from one vocal cord to the other (Fig. 286), generally in 
tlie posterior portion. Tt is also observed as a result of bilateral 
abductor paralysis when complete (Fig. 507). inasmuch as this 
unfortunate condition shuts off the lumen of the larynx. All other 



774 THE LARYNX, 

forms are due to cicatricial contractions, adhesions, acute edematous 
inflammation, or new growths within or without the larynx. Con- 
strictions due to webs may be relieved by cutting- or dilating. 
Permanent relief is sometimes obtained by intubation. 

6. FOREIGN BODIES IN THE LARYNX. 

Small substances of various kinds may enter the larynx. Many 
objects become impacted in the recesses of the larynx, while others 
pass on into the trachea or bronchi. 

They consist of fishbones, bone splinters, nutshells, needles, 
splinters of wood, corns, fruit pits, dental plates, pins (Fig. 539), 
tacks, collar buttons and other metallic objects. As a rule the 
accidental entrance of a foreign body into the larynx results from 
the pernicious habit of holding things in the mouth. The sudden 
inspiration which is the forerunner of a sneeze or paroxysm of 
coughing or laughing draws the object directly into the lumen of 
the larynx. 

Treatment. — Fortunately, in the majority of cases, the patient, 
by means of a sudden and forcible cough, succeeds in ejecting the 
substance from the larynx. In a small percentage of cases, especially 
children, by holding the patient head downward and administering a 
sharp slap upon the back, the foreign body is dislodged and ejected. 

Two surgical methods are employed for removing foreign 
bodies from the larynx, viz., the indirect and the direct. 

The indirect method requires suitable laryngeal grasping 
forceps (Fig. 500) and excellent reflected light. Complete cocaine 
anesthesia is necessary. This method is applicable to adults and 
older children who are tractable. 

The direct method is fully described in the chapter on direct 
laryngoscopy, etc. (Chapter LIII). 

7. PROLAPSE OF THE VENTRICLE. 

Prolapse of the ventricle of Morgagni, otherwise known as the 
saculus laryngis, into the lumen of the larynx is a rare affection. 
Kyle describes it as a separation of the membranous covering of the 
ventricle from its attachment, as a result of which it protrudes into 
the lumen of the larynx. 

Watson Williams has advanced the more probable theory that 
prolapse of the membrane alone never occurs, but that a true infil- 
tration of the underlying tissues forces the membrane from its 
normal position. 

This affection is caused by tumors of various kinds, but more 
especially syphilis, tuberculosis and malignant growths. The prolapse 
may also be caused by pressure from abscesses or aneurisms. Aside 
from the symptoms which characterize the particular underlying 
disease the patient complains of aphonia and dyspnea. The treat- 
ment should be directed to the primary lesion. 

Tuberculosis of the larynx, lupus of the larynx and syphilis of 
the larynx are respectively discussed in Chapters XXIX and XXX. 



CHAPTER L. 

NEOPLASMS OF THE LARYNX. 

The larynx may be the seat of both benign and malignant 
neoplasms. 

1. BENIGN NEOPLASMS. 

The following benign tumors may appear in the larynx, viz., 
papillomata, fibromata, cystomata, angiomata, lipomata, myxomata, 
singers' nodules (see page 769) and chondromata. Of these the papil- 
lomata, fibromata and cystomata are of the most frequent occurrence. 

Etiology. — The exciting cause of benign neoplasms of the 
larynx is not definitely known, but authorities generally agree that 
long-continued laryngeal irritation and inflammation are potent 
predisposing causes. According to Semon, they are more common 
in Germany and France than in England and the United States. 
They are more common in males than in females, and, with the 
exception of multiple papillomata, which often occur in young 
children, they develop in adult life. Benign neoplasms are com- 
paratively common in hucksters, "barkers," singers and public 
speakers. Moritz Schmidt 1 furnishes the following statistics 
regarding the frequency of laryngeal neoplasms, the cases tabulated 
being taken from a series of 32,997 patients treated in his clinic 
and covering a period of ten years : — 

MEN. WOMEN. CASES. 

Fibroma 178 78 256 

Papilloma 31 15 46 

Singers' nodules 56 53 109 

Lipoma 1 1 

Myxoma 3 3 

Fibromyxoma 1 1 

Tuberculous tumors 14 22 36 

Cysts 2 6 8 

Sarcoma 3 3 

Carcinoma 61 15 76 

Tracheal carcinoma 1 1 2 

Pathology. Papillomata. — These warty growths are of various 
size and extent, and are pedunculated, sessile or diffuse. They are 
usually attached to the vocal cords, occasionally to the ventricular 
bands, and rarely to other portions of the larynx. They are made up 
of connective tissue interspersed with round cells and covered with a 
massed layer of stratified epithelium. The color is pale pink with 
rough and uneven surfaces ( Fig. 502 ) . 

Fibromata. — Fibromata usually occur singly. The form is oval, 
the surface even and the color pink. They are made up of rather 



1 New Growths of the Upper Air Passages. 

(775) 



776 THE LARYNX. 

dense connective tissue covered by a thin epithelial layer. They are 
attached to the vocal cords by a broad base, being rarely pedunculated. 

Cystomata, — Cysts usually result from the retention of mucus in 
mucus-secreting glands the mouths of which have become sealed. 
They vary in size and on puncture are found to contain fluid mucus. 
They are attached about the epiglottis, aryepiglottic folds, or protrude 
from the ventricles. Tubercle bacilli and' giant cells have been found 
in the cyst contents. 

Angiomata. — Angiomata are vascular tumors with a broad base. 
They are usually located about the epiglottis or the ventricular bands. 

Lipomaia. — These are tabulated, fatty tumors, yellowish in color, 
with broad bases, usually arising from the aryepiglottic folds. 

Myxomata. — These are smooth, bulbous, semitranslucent masses 
springing singly from the vocal cords. Structurally they are similar 
to nasal polypi, although somewhat denser. 

Chondromata. — Chondromata are irregular, broad-based masses, 
largely made up of hyaline cartilage cells, and are usually attached to 
the cricoid cartilage, but in rare instances they spring from the thyroid, 
the epiglottis or the arytenoid cartilages. 

Symptoms. — Impairment of voice, laryngeal irritation and 
dyspnea are the chief symptoms induced by benign growths in the 
larynx. Small tumors give rise merely to slight irritation and 
hoarseness. As they increase in size aphonia may develop, and when 
the growth encroaches upon the lumen of the larynx respiration 
becomes impeded, until, finally, alarming dyspnea may necessitate the 
removal by operation or relief by resort to intubation or tracheotomy. 

Young children with multiple papillomata, and adults with 
either large papillomata or chondromata are especially liable to 
experience serious dyspnea. Pain is rare. Hemorrhage may be 
expected in angiomata. Cough is neither constant nor severe 
except in young children with multiple papillomata. Hemorrhage, 
dysphagia and pain are remote symptoms. 

Diagnosis. — Remembering the clinical picture described in the 
pathology, the laryngoscopic examination (Figs. 19 and 494) will 
usually establish a clinical diagnosis. Some difficulty occasionally 
is experienced in differentiating fibromata, myxomata and lipomata. 
Malignant growths during the incipient stage are sometimes mis- 
taken for those of benign nature. Benign growths are usually 
painless, non-ulcerating, and are unaccompanied by swelling, infiltra- 
tion or fixation of the cartilages. The converse obtains in malig- 
nancy, and lymphatic gland enlargement develops early. Micro- 
scopic examination may become necessary to establish a definite 
diagnosis. 

Prognosis. — The prognosis is good so far as life is concerned, 
except in children with multiple papillomata, which renders them 
susceptible to fatal dyspnea and pulmonary complications. The 
voice may recover whenever it is possible to remove the growth 
without injury to the vocal cords. Recurrent multiple papillomata, 
even though finally cured, usually result in permanent impairment of 
the voice. In . young children and sometimes in adults multiple 



NEOPLASMS OF THE LARYNX. 



777 



papillomata persist indefinitely, and eventuate in contractions and 
permanent stenosis. 

Treatment. — The employment of caustics, the galvanocautery, 
or rough rubbing with harsh substances, such as dry sponges, is 
open to the criticism that their use is attended with danger of 
serious injury to the surrounding tissues and of severe inflamma- 
tory reaction ; moreover, these measures rarely succeed in destroy- 
ing the tumor. Spraying the larynx with absolute alcohol five or 
six times a day has been advocated for the destruction of small 
papillomatous* growths. 

Benign tumors within the larynx, even 
though of small size, and apparently stationary, 
should always be removed, inasmuch as sooner 
or later they become sufficiently enlarged to 
interfere with phonation. 

There are three general methods for the 
removal of benign growths : 1. By means of 
forceps or snare through the mouth. This re- 
quires the use of the laryngeal mirror, with 
reflected illumination. This method has already 
been described as the intralaryngeal operation, 
or indirect laryngoscopy. 2. By direct laryn- 
goscopy by means of the Jackson or Killian 
tubular speculum (Chapter LIII). 3. By the 
extralaryngeal method (thyrotomy or trache- 
otomy). 

The first method (indirect laryngoscopy), 
long in use, in favorable cases possesses many 
advantages. The patient or an assistant is in- 
structed to grasp the protruded tongue with a 
napkin, holding it firmly between the thumb and 
the index finger. The operator should hold 
the laryngeal mirror in place with the left hand, 
thus bringing the laryngeal picture well into 
view (Fig. 19). He now is able to guide a suit- 
able instrument, preferably a curved laryngeal 

forceps (Fig. 500), into the larynx and to grasp the growth ( Fig. 
502). 

Local anesthesia, both of the pharynx and the larynx, should 
be complete. In the pharynx a 4 per cent, solution of cocaine 
sprayed or swabbed over the mucosa will suffice, but a 10 to 20 per 
cent, solution of cocaine is usually required in order to overcome the 
spasm of the larynx which is induced by instrumentation. Xervous 
patients often require considerable training of the larynx al 
repeated sittings before submitting to the operation. 

The difficulties and dangers are: 1. lark of self-control and 
adaptability on the part of the patient; 2. the wounding or tearing 
of surrounding tissues by the operator. 

Direct Laryngoscopy. — Tin's method is fully described in 
Chapter Fill. It is comparatively a simple and effective procedure. 




Fig. 502.— The la- 
ryngeal forceps in 
position for severing 
a papilloma from the 
vocal cord. 



778 THE LARYNX. 

In adults the removal of benign growths from the larynx can 
usually be accomplished under local anesthesia, with the patient 
in the sitting posture. In young children or in adults who are 
unable to flex the head backward on account of excessive fat, 
rheumatism, gout or some other affection of the neck, the recumbent 
position is necessary. 

Whichever position is used, the tubular speculum (Fig. 526) 
should be used and the entire larynx, including the vocal cords, 
brought into view. It is then a simple procedure to introduce the 
forceps (Fig. 529) and grasp the tumor. 

Tracheotomy. — Of the endolaryngeal operations tracheotomy 
(see Chapter XXXI) is usually performed for the relief of dyspnea. 
Higli tracheotomy, however, enables the operator to remove small sub- 
glottic growths through the tracheal opening. 

Thyrotomy. — Thyrotomy, hereinafter described, is the method 
most commonly employed. This procedure completely exposes the 
growths and permits the requisite surgical measures. 

Subhyoid Pharyngotomy. — Subhyoid pharyngotomy is less 
effective. All extralaryngeal operations subject the patient to con- 
siderable danger of pulmonary complications. Until the advent 
of direct laryngoscopy, extralaryngeal operations have been neces- 
sary in adults for the removal of multiple papillomata, and in young 
children for the removal of large subglottic growths, especially 
when sessile. 

In the removal of angiomata there is considerable danger of 
hemorrhage, and, unless so located that continuous pressure may be 
applied for some time, the growth should be destroyed either by 
repeated cauterizations with the electrocautery, or by electrolysis. 

The removal of chondromata usually requires a thyrotomy and 
the complete removal not only of the tumor, but also of the cartilage 
from which it arises. 

In the removal of cysts it is necessary to destroy or cut away 
a large proportion of the walls ; otherwise there will be a reaccumu- 
lation of the fluid. 

After-treatment. — Whether the entire tumor or a portion only 
is removed, the base or attachment should be rubbed with a 50 per 
cent, solution of lactic acid, and subsequently the larynx should be 
sprayed daily with the medicated oily solutions, or intralaryngeal 
injections (see Chapter XLVIII). Finally, the larynx should be 
inspected at intervals until complete healing has taken place. 

2. MALIGNANT NEOPLASMS. 

Carcinomata, usually of the epithelial type, and sarcomata 
occur primarily in the larynx. The epithelioma is more common 
than the sarcoma. In Ziemssen's report of 68 cases of malignant 
neoplasms of the larynx 57 were carcinomata and 9 were sarcomata. 
Bosworth tabulated 334 cases, 204 of which were carcinomata and 
130 sarcomata. 

Etiology. — As already stated, the cause of cancer still remains 



NEOPLASMS OF THE LARYNX. 779 

unknown. Malignant growths of the larynx usually develop after 
the fortieth year, and they are more common in men than in women, 
the proportion being about 3 J / 2 to 1. Sarcomata sometimes appear 
in young subjects. It is doubtful whether heredity, chronic inflam- 
mations, excessive indulgence in tobacco or alcohol bear any causa- 
tive relation to laryngeal cancer. 

Malignant growths developing primarily within the larynx are 
known as intrinsic growths. When developing secondarily with- 
in the larynx, extending from the tonsils, tongue, pharynx, or 
external tissues, they are designated extrinsic. Clinical differentia- 
tion of the varieties is sometimes difficult. 

Pathology. — Epithelioma and sarcoma are the varieties usually 
found in the larynx. When intrinsic they occur in the fol- 
lowing order of frequency: 1, vocal cords; 2, ventricular bands; 
3, posterior laryngeal walls; 4, ventricles. They develop slowly 
and secondary glandular involvement appears late. The disease is 
primarily unilateral, the first appearance being a congested area, 
with slight thickening, followed by an elevation of fibromatous 
appearance, which, in turn, ulcerates. 

Infiltration and thickening of the surrounding tissues follow, and 
the typical appearance of malignancy — the infiltrated areas, ulcer- 
ated centre and cauliflower-like excrescences — completes the clinical 
picture. 

In the extrinsic variety the appearance of the growth in the 
larynx is followed by a rapid development, inasmuch as more or 
less general infection has already taken place. When the disease 
spreads from the larynx, epiglottis, or aryepiglottic folds, the cervi- 
cal glands become infected early. 

Symptoms. — In intrinsic growths the initial symptoms are 
never severe. Hoarseness is the first symptom complained of, mild 
at the commencement, but steadily progressive until the voice 
becomes aphonic. Continuous hoarseness appearing in individuals 
after the fortieth year should be regarded with suspicion and a 
careful visual inspection of the larynx should be insisted upon. 
The hoarseness is peculiar and unlike that of ordinary laryngitis. 
Almost simultaneously with the development of ulceration slight 
tenderness on pressure appears over the larynx. Dyspnea is a .late 
symptom and is the result of edema or of the encroachment of the 
growth upon the lumen of the larynx. Ulceration marks the ap- 
pearance of secretion, to dislodge which the patient coughs and 
hawks. 

These efforts produce more or less pain, which radiates to the 
tonsil and to the ear. The secretions are usually offensive and 
the breath odorous. In the later stages the expectoration becomes 
mucopurulent and often hemorrhagic. Dysphagia is a late symptom 
and extension to the laryngeal cartilages gives rise to necrosis and 
severe pain. Cachexia develops late and after secondary involve- 
ment has appeared. 

Whenever extrinsic malignant growths invade the larynx, 
extension and ulceration rapidly ensue; meanwhile the aphonia, 



780 



THE LARYNX. 



dysphagia, dyspnea and pain appear in rapid succession. During 
the final stages portions of necrosed cartilage may become detached 
and expectorated. At this time tracheotomy may become necessary 
in order to relieve the alarming dyspnea. 

Diagnosis. — Early diagnosis is of great importance and is 
attended with much difficulty. In intrinsic cases with small dis- 
eased areas at the time of discovery, it is possible to effect a com- 
plete cure by means of a radical surgical removal of the growth. 

In 1896 the author reported a case of primary epithelioma of 
the left vocal cord in a clergyman sixty-six years of age, in whom the 
clinical diagnosis was fibroma. The mass was removed with 




Fig. 503. — Tuberculous ulceration of the larynx. 



Schrotter's tube forceps under cocaine anesthesia. The entire dis- 
eased area covered less than one-half of the entire vocal cord. The 
tumor was examined microscopically by Dr. Jonathan Wright and 
was found to be an epithelioma. The facts were stated to the 
patient and with his consent a partial laryngectomy was performed. 
After passing through an attack of septic pneumonia the patient 
recovered and with sufficient voice to enable him to fulfill the 
duties of his pastorate for several years. In this case the early 
diagnosis of laryngeal cancer rendered it possible to prolong life 
by surgical removal. He lived fourteen years. 

Laboratory examination of all growths removed from the 
larynx, even when considered benign, is a wise precaution. Intrin- 
sic cancer, during the early stages, is not readily differentiated from 
innocent growths, syphilis and tuberculosis. 

Tuberculous ulceration (Fig. 503) is usually a late complication 
of general tuberculosis and the tubercle bacilli are always present. 

The differentiation of syphilis is more difficult, and a course of 



NEOPLASMS OF THE LARYNX. 731 

treatment with iodid of potassium may become necessary. If the 
disease is syphilis there will be definite improvement in about ten 
days. On the contrary, this remedy has no effect upon malignancy. 

Aside from these diseases the clinical history, the examination 
of the larynx, and the microscope usually furnish sufficient -data 
to establish a diagnosis. In extrinsic growths the primary lesion 
usually becomes well marked in advance of the laryngeal involve- 
ment. 

In all doubtful cases a section of the tumor should be sub- 
mitted to a microscopical examination, providing all arrangements 
have previously been made for immediate operation in case the 
pathologist confirms the clinical diagnosis and the case is con- 
sidered operable. It is well known that a partial removal or any 
partial operative procedure upon a malignant growth of the larynx 
is almost immediately followed by a marked acceleration in the 
activity of the growth; hence, the major operation should not be 
delayed. The section for microscopical study should be of con- 
siderable size, cut deep, and should contain a portion of the border 
of the growth. It is usually possible to remove a suitable section 
under cocaine anesthesia. Failure to remove a proper section of 
the tissue accounts for many unsatisfactory laboratory reports. A 
negative laboratory diagnosis should never be considered final in 
the face of distinct clinical evidence of malignancy. The clinical 
versus the microscopical diagnosis has been the subject of much 
discussion. Both should receive due consideration, and in a given 
case, if either method favors the diagnosis of cancer, the interest of 
the patient will be best conserved by relying upon such evidence. 

Prognosis. — Extrinsic malignant growths of the larynx are 
almost invariably fatal, but life may be prolonged for months or even 
years in patients who submit to operation before the epiglottis 
becomes involved or metastases have appeared. Intrinsic growths, 
being more localized and of slower development, give greater 
promise of recovery if radically extirpated during the early stages, 
by external operation. Especially is this true in unilateral .cases 
with little or no ulceration. Tumors of this type may be removed 
by thyrotomy, a procedure which minimizes the postoperative 
dangers. It is unfortunate that a large proportion of general prac- 
titioners never employ the laryngeal mirror, thereby neglecting the 
golden opportunity to establish an early diagnosis in suspicious 
cases, the laryngologist being consulted only after the disease has 
extended over a large area. 

Treatment. — ( hying to the lack of knowledge of the etiology of 
cancer, medicinal treatment has failed to stay its progress. Surgical 
removal constitutes the only method of treatment which oilers the 
slightest hope of cure. The diagnosis having been established, there 
should be no delay in operating, unless the disease has already pro- 
gressed beyond operable limits. The primary Eocus is usually uni- 
lateral and remains so for s< ime months, and even after considerable 
extension into the surrounding area- of the interior of the larynx the) 
do not become extrinsic until the final stage has been reached. The 



782 THE LARYNX. 

lymphatics within the larynx seem to have no well-established connec- 
tion with those outside, and extension externally is, therefore, long 
delayed. Intralaryngeal operation is inadequate for the removal •;'" 
malignant growths and should never be employed. Removal by 
external operation gives much promise of ultimate success in incipient, 
intrinsic cancer of the larynx. 

Three methods of operation are applicable, depending largely 
upon the extent of the disease: thyrotomy ; partial laryngectomy, 
and complete laryngectomy. 

Thyrotomy (Laryngofissure). — Of the three external opera- 
tions thyrotomy is the simplest, the least dangerous, and usually it 
results in less impairment of voice. Unfortunately, it is applicable 
only to cases where the disease is localized, and practically confined 
to the soft tissues. During recent years the results obtained from 
this method of procedure by Semon, Butlin and others in selected 
cases have been most favorable. 

Technique. — According to Butlin, the steps of the operation are 
as follows : — 

"The usual rules regarding asepsis having been complied with, 
the patient is placed upon the back with the shoulders and neck 
elevated sufficiently to produce some tension upon the soft tissues 
which cover the larynx. 

"A median incision should then be extended from the hyoid bone 
above to about 1 inch from the sternum. Having severed the soft 
tissues, the hemorrhage should be controlled by means of artery 
clamps and ligatures. The trachea is then opened for the purpose 
of inserting a Halms tracheotomy tube. During the interval 
required for the sponge to swell and thereby block the intervening 
space in the lumen of the larynx, the artery clamps may be released 
by applying ligatures. 

"The thyroid cartilage is then divided exactly in the median 
line. Considerable care should here be exercised to prevent injury 
to the vocal cords. By cutting from below upward and precisely 
following the median line this danger is reduced to the minimum. 

"The incision should now be extended through the cricothyroid 
membrane. The laryngeal incision is then spread wide open, either 
by blunt retractors or preferably by traction from strong silk 
threads carried through each section of the divided cartilage. All 
oozing of blood should then be controlled by a temporary packing 
of the operating field with gauze soaked with a 1 : 2000 solution of 
adrenalin chlorid. The growth should then be outlined and an 
incision extended around it at a distance of at least % of an inch 
from its free border. 

"The soft tissues included in the incision are then removed and 
the operation is completed by curetting the underlying cartilage 
and by cauterizing the area with nitric acid or the galvanocautery. 
The free borders of the cartilage are then coaptated and united by 
means of absorbable sutures and the external wound closed in the 
usual manner, except that the soft parts covering the tracheal 



NEOPLASMS OF THE LARYNX. 783 

wound are left open after withdrawing the Hahns tube for the 
purpose of quick drainage." 

Partial Laryngectomy (Hemilaryngectomy). — Partial laryn- 
gectomy is permissible in cases wherein the disease is known to be 
confined to one side of the larynx, even though the underlying 
cartilages may be somewhat involved. Under all circumstances 
it is a grave operation. 

Technique. — The initial steps in the technique are similar to 
those of thyrotomy. In the removal of the tumor a part or the 
whole of the lateral half of the larynx is removed, depending upon 
the extent of the growth. 

Complete Laryngectomy. — Complete laryngectomy under all 
circumstances is a formidable and dangerous operation, but in cases 
where the disease is bilateral it offers the only hope of permanent 
cure. 

Technique. — The technique herein described is mainly that of 
Solis-Cohen, and the steps are as follows : — 

1. A preliminary low tracheotomy two to four days before the 
major operation. 

2. Make a median line incision from the hyoid bone to the 
ensiform cartilage. 

3. If necessary make two transverse incisions from the upper 
extremity of the primary incision. 

4. Divide all soft tissues from the anterior and lateral surfaces 
of the larynx and spread the wound widely with retractors. 

5. Anchor the trachea to the external wound by passing two 
sutures through the first and second rings in order to prevent the 
lower portion from dropping into the mediastinum after sewing. 

6. Separate the larynx from the esophagus by means of a 
blunt elevator. 

7. Sever the trachea from the cricoid, or lower down if neces- 
sarv. 

' 8. In severing the upper portion of the larynx from the esopha- 
gus great care should be exercised to preserve as much of the latter 
as the ravages of the disease will permit. Sometimes it is possible 
to leave the arytenoids and even the epiglottis unimpaired. 

9. Open the pharynx through the thyrohyoid membrane, and 
separate the larynx from its pharyngeal attachment by mean- of 
scissors. 

10. Close off the pharynx from the lower wound by the fol- 
lowing steps: (a) Unite the edges of the pharyngeal opening in a 
vertical line by means of a row of sutures. Keen stitches the lower 
pharyngeal membrane to the thyrohyoid membrane at a poinl below 
the hyoid bone, (b) Unite the pharyngeal aponeurosis by sutures. 
(c) Draw the deep muscles toward the median line and unite the 
free borders by sutures, (d) Unite the superficial muscles in a 
similar manner. (V) Suture the stump of the trachea to the exter- 
nal wound, (f) Close the external wound except around the 
tracheal orifice and apply sterile gauze dressings. 



784 THE LARYNX. 

Treatment of Extrinsic Growths. — Rarely is it possible to 
remove an extrinsic growth in its entirety, including all lymphatic 
involvement, and then only by the most extensive dissections which 
combine complete laryngectomy with some form of pharyngotomy. 
Furthermore, patients who submit to this operation usually are 
obliged to wear an artificial larynx thereafter, the discomforts of 
which are very great. 

The results of all external operative procedures upon the larynx 
are unfavorably influenced in those who have other associated organic 
diseases, especially diabetes, Bright's disease and cardiac lesions; also 
in individuals in advanced life. Extensive lymphatic gland involve- 
ment is an insurmountable barrier to success. Before attempting an 
operation involving so much danger to life, and with after-conditions so 
fraught with discomfort, a full statement of all facts should be made 
to the patient, leaving him to make the final decision. It is the author's 
conviction that, in advanced cases, life is further prolonged and with 
no greater suffering by cleansing and palliative local applications, and 
sufficient morphine to control pain. A tracheotomy should be per- 
formed whenever the laryngeal stenosis becomes distressing. Insuffla- 
tions of orthoform and morphine after cleansing with alkaline sprays 
or normal salt solution relieve the discomfort. Dysphagia may be 
relieved by spraying the entire throat and larynx with a 2 per cent, 
solution of cocaine twenty minutes before meals. In advanced cases 
feeding through an esophageal tube, rectal alimentation, or even 
gastrotomy may become necessary in order to sustain life. 



CHAPTER LI. 
NEUROSES OF THE LARYNX. 

The various neuroses of the larynx have to do either with the 
sensation or motion of this organ. Hence they are' primarily 
classified as : — 

1, sensory, and, 2, motor disturbances. 

1. NEUROSES OF SENSATION. 

Sensory neuroses are relatively rare and are chiefly confined to 
the terminal nerve filaments in the laryngeal mucosa. They are 
classified in conformity with their clinical manifestations into (a) 
anesthesia; (b) hyperesthesia and paresthesia; (c) hyperalgesia or 
laryngeal neuralgia. 

(a) ANESTHESIA. 

Etiology. — This affection is usually due to some form of 
neuritis of the terminal filaments of the superior laryngeal nerve, 
and is most commonly observed as a sequela of diphtheria and, 
rarely, of cholera. Hysteria is believed to be the cause in a limited 
proportion of cases. When of central origin it usually occurs as a 
symptom of bulbar paralysis or tabes. 

Unilateral anesthesia is observed in cases of laryngeal paralysis 
from hemiplegia. 

Symptoms. — The area of anesthesia may either be general or 
circumscribed. When general the entire laryngeal mucosa loses 
its normal irritability to touch and no cough or spasm is induced 
when a probe or applicator is passed into the larynx. Aside from 
the actual loss of sensation the most common symptom is the 
tendency for food and drink to pass into the larynx and trachea. 

Diagnosis. — The diagnosis is based upon the loss of sensation 
to the touch of the probe. 

Prognosis. — The prognosis depends upon the primary cause of 
the disease. It is grave in all cases of central origin, but when the 
affection results from diphtheria or hysteria the prognosis is good 
and recovery may be expected in a few weeks. 

Treatment. — Except in cases of central origin the treatment 
should consist of general hygienic measures, principally out-of-door 
life in a bracing atmosphere, and the internal administration of 
suitable tonics in the form of iron and strychnia. When accom- 
panied with paralysis- of the laryngeal muscles it is important to 
adopt measures for preventing the entrance of food into the larynx. 
This is best accomplished by tubal feeding, or by having the patient 
assume the dorsal position while eating. Electricity in the form 
of the galvanic, faradic, or high-frequency current, applied locally, 
is of some benefit. 

50 (785) 



786 THE LARYNX. 

(b) HYPERESTHESIA AND PARESTHESIA. 

Etiology. — Some increase in the sensibility of the larynx is 
common even among healthy individuals. The increased or hyper- 
sensitiveness is characterized by attacks of cough or even laryn- 
gospasm, upon the slightest touch or stimulus applied to the 
laryngeal mucosa. Such irritability, however, soon subsides and 
the patient becomes able to endure the stimuli without reflex 
symptoms: Persistent catarrhal inflammation of the upper air 
passages, particularly in those who indulge in tobacco or alcoholic 
excesses, is provocative of hyperesthesia of the laryngeal mucosa. 
The laryngeal mucosa of tuberculous and anemic persons is par- 
ticularly susceptible to changes of temperature, smoke, dust or the 
slightest pressure upon the throat. The apprehension of impending 
cancer, tuberculosis or syphilis, which is aroused by nervous 
indigestion in neurasthenics, is a common cause of this affection. 

Symptoms. — The milder symptoms consist of a disagreeable 
sensation of burning, pricking, dryness, constriction and rawness 
in the larynx. The phonophobia on the part of the tuberculous 
and of various reflex disorders is commonly due to a more or less 
abnormal sensitiveness in the mucous membrane of the larynx. 
The truly nervous laryngeal cough, however, according to Macken- 
zie "occurs without any altered sensibility of the larynx" at all. 
The mucosa is extremely irritable to the touch, and cough and 
"tired" voice is common. The mucous membrane is often con- 
gested, but may be anemic. 

PARESTHESIA. 

Paresthesia of the larynx is almost invariably associated with 
hysteria and is characterized by perverted sensations in the larynx. 
Persons who by occupation are obliged to use their voices much 
are frequently the sufferers from a morbid sensibility of the larynx 
which causes them to suspect the presence of a foreign body in the 
throat. More frequently the patient is apprehensive or even 
hysterical, and complains of a lump in the throat, violent pain or 
spasm. 

Treatment. — The treatment of hyperesthesia and paresthesia 
in their simpler forms should aim to relieve the patient's baseless 
apprehensions regarding serious organic diseases, such as tuber- 
culosis and cancer. The surgeon should, if possible, gain the 
patient's full confidence, meanwhile impressing upon him the fact 
that his affection is a simple matter which requires only the co- 
operation of both patient and physician in order to effect a cure. 

As a rule it is unwise to recommend home treatment for the 
throat or to administer frequent office treatments unless it is thought 
wise to make use of a placebo for a time. In case the patient has 
a simple chronic laryngitis he should be subjected to the measures 
heretofore defined for that affection. When accompanied by faulty 
digestion he should be advised regarding his food, exercise and 
habits. Intratracheal injections of camphor and menthol, each 2 



NEUROSES OF THE LARYNX.- 787 

per cent, in benzoinol, afford much relief. Whenever anemia is 
present the administration of iron is beneficial. 

(c) HYPERALGESIA OR LARYNGEAL NEURALGIA. 

Laryngeal neuralgia is a comparatively rare affection, character- 
ized by intermittent attacks of pain in the larynx. It is usually 
unilateral, intermittent, and is generally relieved by pressure. As a 
rule it is confined to the local area supplied by the superior laryngeal 
nerve. It is usually preceded by a history of a cold, but it may occur 
from the pressure of new growths. Avellis affirms that the spot where 
the superior laryngeal nerve penetrates the thyrohyoid membrane, 
between the hyoid bone and thyroid cartilage, is the pressure point of 
greatest pain. It is worthy of note that this is the precise spot that is 
complained of in the laryngeal crisis of locomotor ataxia. The affec- 
tion may be due to rheumatism, gout or malaria. 

Prognosis. — Usually the prognosis is favorable, although the 
course of the affection may be prolonged. 

Treatment. — The treatment must be directed to the primary 
cause of the affection in each individual case. Apart from the 
neurasthenic element involved it is probable that a considerable 
proportion of these laryngeal dysesthesias are of rheumatic nature 
and as such are to be treated by potassium or the salicylates. 

Whenever it can be determined that the affection is due to 
some constitutional dyscrasia, appropriate general treatment, 
adapted to the individual case, should be adopted. In gouty affections 
asperin (15 to 30 grs. a day) will afford relief. In case of malaria 
quinine is indicated. The intratracheal injections (see Chapter 
XLYIII) relieve the pain and irritation, while hot fomentations applied 
externally during the paroxysms afford relief. 

2. NEUROSES OF MOTION. 

The motor neuroses of the larynx are characterized either by 
loss or perversion of power or movement. When the affection is 
characterized by a loss of power it is known as paralysis; if due to 
perverted power it is known as spasm. To the one or other of these 
two primary classes all neuroses of motility belong. A further 
analysis determines whether the lack of motility lies in the tissues 
of the muscles or in disease of the nerves that control them. If 
found in the muscles it is termed myopathic. If it originates in the 
nerves it is classified as neuropathic. The muscles thai ma) be 
involved are enumerated as follows : — 

Group 1. The. lateral crico-arytenoids. I 

The superior portions of the thyroarytenoids. [ ^.ddui toi 
The arytenoids. I 

Group 2. The internal thyroarytenoids. Internal tensors. 

t-, ,. -if External ten 3< trs 

The cricothyroids. - ,- , , , 

I. of the vocal cords. 

Group 3. The thyro-epiglottics. ] Sphincters 

The aryteno-epiglottics r or 

All the adductor muscles. ) constrictors. 
Group 4. The crico-arytenoids. Abductors. 



788 THE LARYNX. 

The chief functions of groups 1 and 2 is that of phonation; of 
group 3, deglutition ; of group 4, respiration. 

The position of the vocal cords during forced inspiration is 
shown in Fig. 504; that of quiet inspiration in Fig. 505, and during 
phonation in Fig. 20. With the exception of the cricothyroids and 
a portion of the arytenoids the entire list of the above-mentioned 
muscles receive their nerve supply from the recurrent laryngeal 
nerves. The cricothyroids and the arytenoids, in part, are supplied 
by the superior laryngeal nerve. 

It is obvious that an inflammatory process of sufficient severity 
to produce inflammatory changes in the mucous membrane and 
deeper tissues of the larynx is equally sufficient to induce disturb- 
ances of function of the type known as muscular paresis. The 
"tired" voice of the professional singer or orator, due to prolonged 
overstrain of voice or a too frequent use of unusual registers, called 
by Frankel mogiphonia, may be regarded as paresis of this type. 








Fig. 504. — Position of the Fig. 505. — The position of the 

vocal cords during forced in- vocal cords during ordinary in- 

spiration, spiration. 

While this is true, myopathic paralysis seldom exists without 
affecting its corresponding nerve. According to Ross, "we must 
assume that the inflammatory process, considering the intimate 
relation between a muscle and its nerve in the larynx, very easily 
spreads from the muscular tissue to the supplying nerve branches, 
and, again, a neuropathic paralysis, if existing for some while, may 
be accompanied by paresis of the corresponding muscle through 
what is called 'atrophy of inactivity.' Hence it follows that it will 
very frequently be impossible, or at least very difficult, to dis- 
tinguish by means of the laryngoscopic image a myopathic from 
a neuropathic affection." 

Furthermore, as the seat of the disease may be anywhere in 
the nerve from its root in the floor of the fourth ventricle to its 
termination in the larynx, we naturally divide them again into 
central or peripheral paralyses according as they have their origin 
in the central nervous system (Fig. 506) or in a disease of the 
nerve at its periphery in the larynx. It will thus be seen that the 
character of the paralysis of the laryngeal muscles depends upon 
whether the origin is to be sought in the nervous centres which 
govern their action, or in the endings of the nerves themselves. 



NEUROSES OF THE LARYNX. 



789 



1. CENTRAL PARALYSIS. 

Fortunately, outside of the functional or hysterical paralyses 
of the larynx due to lesions in the central nervous system, cases 
of central origin are exceedingly rare and are seldom seen except in 
locomotor ataxia, multiple sclerosis and bulbar paralysis. And equally 
fortunate is the fact that their diagnosis is never difficult, for here the 
Semon-Rosenbach law is of great value, viz., "in all functional 
paralyses of the larynx the constrictors of the glottis (adductors) 
are almost always affected ; in all the organic and progressive 
organic paralyses, whether central or peripheral in origin, the 
dilators of the glottis (abductors) are at first or exclusively 
affected." 




Fig. 506.— Diagrammatic representation of the centers of respiration 
and phonation in the brain and medulla oblongata and their tracts (after 
Rethi). The cortical center of phonation (P) is functionally more im- 
portant, and, therefore, better developed, than the cortical center of res- 
piration, r; on the other hand, the medullary (bulbar) center of respira- 
tion, R, is functionally of greater importance than the medullary center 
of phonation, />. The more important centers are thus marked with capital 
letters; the minor centers, with small letters; the black non-interrupted 
lines (S.s) show the course of the fibers for the narrowers ; the lines O,o, 
those (dotted) for the dilators of the glottis. (Ross, with permission.) 



And it may further be observed that the most marked char- 
acteristic of laryngeal paralysis of central Origin is that other 
nerves become implicated. For instance central paralyses of tin- 
larynx, when due to organic disease, never appear alone, inasmuch 
as loss of power in some other mnsclc of the head, face, or 
extremity simultaneously ocenrs. Hence a history oi a sudden 
loss of voice with an equally sudden return occurring in women a1 
the period of puberty, pregnancy or the menopause, or anion- men 
hysterically inclined, or afflicted with nasal, pharyngeal, or laryn- 
geal hypertrophies, and, especially when the image in the laryn- 
goscope is that of paralysis of both adductors, it may he assumed 
that t lie affection is functional and not organic. 



790 THE LARYNX. 

Prognosis. — The prognosis in these cases is generally good. 

Treatment. — The surgeon should at the outset endeavor to 
gain the full confidence of the patient and meanwhile he should 
speak hopefully regarding the outcome. It is unwise to mention 
the word hysteria, but rather to assume that the affection is real 
but curable. If any pelvic disorders are discovered they should 
receive proper treatment. It is also important that any accom- 
panying disease of the upper respiratory tract should be attended 
to and the general health and hygiene should, if possible, be 
improved by tonics, rest and proper exercise. 

Full advantage should be taken of suggestions regarding the 
improvement of voice which may be expected to ensue, and even 
hypnotism may be resorted to with excellent results. A sudden 
shock from an electric current, or the passing of a probang into the 
larynx, has been known to restore the voice in patients who have 
been properly prepared by suggestion. The author has repeatedly 
succeeded in restoring the voice by direct application of weak silver 
or iron solutions to the larynx after having instructed the patient 
to say "John," "Mary," or some other word just at the instant when 
the probang is withdrawn. 



2. PERIPHERAL PARALYSIS. 

Our use of the word here covers the entire course of the nerve 
from the time it leaves the cranium to its termination in the larynx, 
and the symptoms are governed by the exact spot "at which the nerve 
is affected. It is obvious that many factors may disturb or destroy the 
functions of the laryngeal nerves. According to Ross : "In lesions 
above the branching off of the superior laryngeal nerve all of the 
laryngeal muscles of the same side are paralyzed, and there is anes- 
thesia of the corresponding half of the laryngeal mucous membrane, 
and the pulse rate is generally increased, even up to 160. In lesions 
between the origins of the two laryngeal nerves there is no anesthesia 
but only paralysis of the muscles. In lesions below the recurrent the 
larynx remains intact, while the cardiac symptoms may be alarming. 
If. in addition, the pharyngeal branches are paralyzed, we shall 
also find paralysis in the pharynx and anesthesia of the palate." 
For convenience of description peripheral paralyses are classified as 
follows : — 

A, Paralysis induced by disease or traumatism of the recurrent 
(inferior) laryngeal nerve. 

B, Paralysis induced by disease or traumatism of the superior 
laryngeal nerve. 

A. PARALYSIS INDUCED BY DISEASE OR TRAUMATISM OF 
THE RECURRENT (INFERIOR) LARYNGEAL NERVE. 

Owing to its exposed position, paralysis of this nerve is com- 
paratively frequent, and its causes may be sought in : (a) Nearby 
diseases, such as aneurism of the aortic arch on the left, or the 



NEUROSES OF THE LARYNX. 791 

innominate or subclavian arteries on the right, destructive processes 
at the apex of the lung, carcinoma of the esophagus, enlarged 
lymphatic glands, goitre, tumors of the mediastinum, pleurisy and, 
occasionally, pericarditis. (&•) Traumatic injuries such as result 
from operations, stabbing and attempts at suicide, (c) Varied 
neuritic and perineuritic inflammatory processes due to such infec- 
tious diseases as diphtheria, influenza, typhoid fever, and, occasionally, 
rheumatic and scarlet fever; or the ingestion of large doses of such 
drugs as atropine, lead and arsenic. The various types of paralysis of 
the recurrent laryngeal nerve are defined in the following order : — 

1. BILATERAL ABDUCTOR PARALYSIS. 

Etiology. — As we have already observed, the act of abduction is 
performed by the posterior crico-arytenoid muscles. Paralysis of 
these muscles is of two general types, viz., neuropathic and myo-* 
pathic. In the majority of all cases the lesion is central and arises 



- ■£ 



Fig. 507.— Bilateral ab- Fig. 508.— Bilateral ab- Fig. 509.— Paralysis of 

ductor paralysis during ductor paralysis during the left abductor as seen 
inspiration. expiration. " during forced inspira- 

tion. 

from degenerative changes which are induced by syphilis, tabes 
dorsalis and bulbar paralysis. In rare instances a "bilateral involve- 
ment of the recurrent laryngeal nerves may arise from the pressure 
of mediastinal tumors, aneurism, goitre and cancer of the esopha- 
gus. This affection arises from peripheral causes (above defined) 
with extreme rarity. 

Bilateral abductor paralysis is more common among men than 
women and is usually an affection of adult life, although a few 
cases have been reported among children. Whether myopathic Mi- 
neuropathic in origin it is invariably a condition of grave import. 
A lone-continued paralysis of the posterior cricoarytenoids should 
invariably lead to a suspicion of locomotor ataxia. 

Symptoms. — Bilateral abductor paralysis is characterized by a 
gradually increasing inspiratory dyspnea which is aggravated by 
the least exertion. The dyspnea is accompanied 1>\ a marked 
stridor during sleep, and later on during the waking hours. The 
laryngoscopic picture I Figs. 507 and 508 I is characteristic, inasmuch 
as the cords assume a fixed position in the median line and open 
but slightly during inspiration. 

There are but two other conditions which are liable to be 
confounded with this affection, viz.. bilateral ankylosis of the 



792 THE LARYNX. 

cricoarytenoidal joint, and a perverted action of the vocal cords or 
spasm. But differentiation is never difficult. In ankylosis the 
cords are straight, tense and utterly without movement, while in 
paralysis they are flaccid and show a tendency to be sucked in 
toward the median line during inspiration (Fig. 507), and puffed 
upward and outward during expiration. 

Equally sharp is the distinction between the so-called per- 
verted action of the cords and true bilateral abductor paralysis, for 
in spasm the movement is intermittent in character and more or less 
short in duration. Furthermore, by adopting the simple expedient of 
inducing the patient to keep on repeating, i.e., until the breath is 
exhausted, a perfectly normal abduction will take place with his next 
inspiration, showing that no real paralysis of the abductors has existed. 



2. UNILATERAL ABDUCTOR PARALYSIS. 

Etiology. — Unilateral abductor paralysis (Fig. 509) is rarely 
caused by a central lesion. It is usually induced by pressure upon 
the trunk of the recurrent nerve, by aneurisms, malignant growths, 
goitre, gummata, or enlarged glands. When of central origin it is 
due to tabes or syphilis and usually eventuates in the bilateral 
form. Cases have been reported wherein the affection has arisen 
from toxemic neuritis as a result of diphtheria, typhoid fever, or 
from lead poisoning. Finally, it may result from traumatism. 

Symptoms. — The symptoms differ materially from those of 
the bilateral form. They are mild and are free from paroxysms of 
dyspnea. Aside from a slight loss of strength and flexibility of 
voice and a possible shortness of breath on exertion, no clinical 
symptoms may be detected except that the cord of the affected side 
remains practically stationary during respiration (Fig. 509). 
Whenever the affection is primarily due to a central lesion, it may 
be expected that sooner or later both sides will become involved. 

Consideration of the prognosis and treatment for both these 
forms of paralysis is deferred until the end of the following 
section. 

3. COMPLETE PARALYSIS OF THE RECURRENT NERVE. 

Reference has already been made to the fact that all the adductor, 
abductor and tensor muscles of the larynx, with the single exception 
of the cricothyroids, are supplied by the inferior or recurrent laryngeal 
nerve ; hence, by complete paralysis of the recurrent nerve we mean a 
paralysis of all the muscles involved or an advanced stage of abductor 
paralysis. According to Semon's law, the abductors are the first to 
succumb. This, if due to progressive central lesions, or continuous 
pressure upon the nerve trunks, will, sooner or later, be followed by 
paralysis of all the remaining muscles of the larynx, with the single 
exception of the cricothyroid, which is supplied by the superior laryn- 
geal nerve. .This condition marks the final stage of bilateral abductor 
paralysis. 



NEUROSES OF THE LARYNX. 



^93 



Symptoms. — The symptoms depend upon whether one or both 
sides of the larynx are affected : — 

(a) Unilateral Paralysis of the Recurrent Laryngeal Nerve. — A 
characteristic symptom is an alternation in the voice, due, no doubt, 
to the undue escape of air from failure of the glottis to close in 
response to the patient's efforts to produce tones (Fig-. 510). The 
patient's ability to speak and breathe are still retained (Fig. 511) 
for the reason that, while the affected cord assumes and always 



m 




Fig. 510. — Paralysis of 
the right recurrent laryn- 
geal nerve during inspi- 
ration. 



Fig. 511. — Paralysis of 
the right recurrent laryn- 
geal nerve during phona- 
tion. 



remains in the cadaveric position with its inner edge concave from 
paralysis of the tensor and the tip of the arytenoid cartilage unduly 
prominent, the healthy cord upon its opposite side will on phona- 
tion cross the median line (Fig. 512) and thus fall into apposition 
with the cord of the diseased side. 

(b) Bilateral Paralysis of the Recurrent Laryngeal Nerve. — Here 
we reach the ultimate of all neuroses of the larynx (Fig. 513), inas- 
much as nearly all the laryngeal muscles are paralyzed. With the 



@ 



Fig. 512. — Paralysis of the right recurrent laryngeal nerve during 
phonation. The left vocal cord crosses the median line in order t" 
compensate for the loss of motion in its oDponent. 



vocal cords, both in phonation (Fig. 514) and respiration, set in the 
"cadaveric position," dyspnea absent except on exertion, with 
extreme difficulty in coughing and speaking, and with no muscular 
power to clear the throat or to prevent the entrance of food and 
liquids into the larynx, a clinical picture of this hopeless malady is 
presented. In the majority of neuropathic cases of central origin 
the patient succumbs to the primary disease Ion- before the laryn- 
geal paralysis has completed its work. The following paragraphs 
are devoted to the prognosis and treatment of the three forms of 
abductor paralysis above described. 



794 THE LARYNX. 

Prognosis.^The prognosis is governed by the underlying 
cause of the affection. In cases which are of central origin or are 
the result of prolonged and permanent pressure the paralysis will 
remain incurable. In bilateral abductor paralysis it is often neces- 
sary to resort to tracheotomy in order to prevent a sudden fatal 
issue from suffocation. The prognosis is more favorable in uni- 
lateral cases and in those neuropathic cases in which it is possible to 
remove the pressure upon the nerve trunks. It is still more favor- 
able in recent cases which are due to toxic neuritis or to trauma. 

Treatment. — Primarily the treatment must be directed to the 
underlying cause of the affection, and secondarily to the relief of 
the paralysis and its attendant symptoms. When the lesion is 
central, syphilis should be suspected regardless of whether the 
symptoms are those of tabes or bulbar paralysis. Hence iodid of 
potassium in full doses should be administered. When due to 
toxemia from lead or arsenic the same internal treatment is indi- 
cated, except that it be daily preceded by early morning doses of 





• 



Fig. 513. — Cadaveric Fig. 514. — Bilateral pa- Fig. 515. — Bilateral ad- 
position of the cords in ralysis of the recurrent ductor paralysis of the 
bilateral paralysis of laryngeal nerve during larynx, 
the recurrent laryngeal extreme effort to pho- 
nerve. nate. 

magnesium sulphate and sulphuric acid, while the evil effects of 
diphtheria, influenza, typhoid and other fevers should be met by 
good diet, change of air and free doses of strychnine and iron. 

Myopathic cases when due to local syphilitic lesions in the 
muscles and other structures in the vicinity of the larynx call for 
the mercurial inunctions in addition to the iodid of potassium, 
while those of traumatic origin must be treated by absolute rest in 
bed, the prohibition of all efforts to talk and the employment of 
such surgical measures as the individual case may require. 

The direct application of electricity is an entirely useless pro- 
cedure in cases in which the paralysis has remained permanent for 
a long period, and especially so when the paralysis is bilateral and 
due to a central lesion or to pressure from aneurism or malignant 
growths. In recent cases which are due to toxemia or traumatism 
and in certain unilateral paralyses some benefit may be obtained 
from daily applications of the high-frequency current. Likewise 
in hopeful cases a systematic course of massage, careful hygiene, 
diet and exercise should be inaugurated. 

In bilateral abductor paralysis when accompanied by paroxysms 
of dyspnea the treatment is entirely surgical and tracheotomy (see 



NEUROSES OF THE LARYNX. 795 

Chapter XXXI) constitutes the only means of relief from the dyspnea 
and from the danger of sudden death from suffocation. The danger 
of delay should be fully explained to the patient, and, unless imme- 
diate relief should follow the adoption of local measures of treat- 
ment and the internal administration of the iodid of potash, there 
should be no delay in operating. 

The author is in full accord with the recommendations of 
Semon that, unless objective widening of the glottis be obtained by 
treatment within a short time, tracheotomy ought to be performed 
without delay. 

4. ADDUCTOR PARALYSIS OF THE LATERAL, CRICO- 
ARYTENOIDS AND THE ARYTENOIDS. 

Unless preceded by paralysis of the abductor muscles the cause 
of adductor paralysis is either functional or myopathic. 

When functional it is usually induced by exhaustion from dis- 
ease, prolonged anxiety or nervous strain, anemia, hysteria and 
uterine disorders. 

When of myopathic origin it is primarily due to acute or 
chronic laryngeal inflammation. It occurs chiefly among anemic, 
hysterical women and rarely in men or young children. 

Symptoms. — Complete aphonia is the characferistic symptom 
of the functional type. The attack is sudden and terminates with 
equal suddenness. In rare instances the aphonia is confined to the 
speaking voice and the patient is able to indulge in coughing or 
laughter or sneezing. When of myopathic origin the aphonia is not 
complete, but the voice is hoarse; it tires easily and requires much 
strain in production. The laryngeal picture is either that of flabby, 
almost immovable cords occupying about the usual position of 
ordinary respiration (Fig. 515), or they may be made to partially 
or wholly approximate momentarily, only to resume the wide-open 
state. 

Prognosis.— In the majority of cases the prognosis is good, and 
recovery, often after many relapses, is the rule. When the aphonia 
is due to long-continued chronic laryngitis or phthisis it usually 
remains permanent. 

Treatment. — The underlying cause should be determined and 
if possible removed. Tonics, especially strychnia, out-of-door life 
in hygienic surroundings, cold sponges, massage and liberal diet 
are most beneficial. Complete rest of the voice often proves a 
curative measure. In hysterical women the measures advised for 
the treatment of hyperesthesia of the larynx are applicable. 

In myopathic cases the treatment heretofore outlined Eor acute 
and chronic laryngitis is indicated. Daily applications of the faradic, 
high-frequency or galvanic current, both intralaryngeally and exter- 
nally, to the affected muscles may prove of some benefit. 

Treatment of a more general character calls For the ordinary 
antihysterical procedures, such as the use of the cold-water plunge, 
and tlie inhalation of chloroform in extreme ca-e-. 



796 THE LARYNX. 



5. PARALYSIS OF THE ARYTENOIDEUS. 

This affection is caused by chronic inflammation of the laryn- 
geal mucosa, incipient phthisis, hysteria, diphtheria, exhaustion 
from lingering diseases, and traumatism. It is frequently accom- 
panied by paralysis of the lateral abductors. 

Symptoms. — Feebleness, hoarseness, and, at times, loss of 
voice are the characteristic symptoms of this disease, the laryngo- 
scope showing that, while the cords approximate well in the anterior 
three-fourths of the glottis, the posterior portion remains open (Fig. 
516), thus leaving a triangular opening between the cords in that 
situation. The treatment is similar to that of adductor paralysis. 

6. PARALYSIS OF INTERNAL TENSORS. 

This type of paralysis is found largely among professional 
singers and speakers, and is due to an overstrain or overfatigue of 
the voice. This condition is generally ascribed to a paralysis of 

@ @ o 

Fig. 516. — Paralysis of Fig. 517. — Bilateral pa- Fig. 518.— Bilateral pa- 

the arytenoideus muscle. ralysis of the internal ralysis of the internal 

tensors during respira- tensors during phona- 

tion. tion. 

the internal thyroarytenoids, although many authors believe that 
some of the fibres of the lateral crico-arytenoid muscles may be 
involved. If due merely to fatigue it can easily be overcome, but 
if from actual strain months of complete rest may be necessary in 
order to effect a cure. In all other respects the causes are precisely 
the same as the preceding variety. It may either be bilateral or 
unilateral. In the laryngeal picture the cords appear concave (Fig. 
517) so that when phonation is attempted an elliptical gap appears 
in the middle third (Fig. 518). The treatment is precisely similar 
to that of adductor paralysis above described. 

B. PARALYSIS INDUCED BY DISEASE OR TRAUMATISM OF 
THE SUPERIOR LARYNGEAL NERVE. 

Barring the sphincters or closers of the glottis, the only muscles 
supplied by the superior laryngeal nerves are the cricothyroids 
(external tensors). Furthermore this nerve supplies not only 
motion to the muscles but sensation to the laryngeal mucosa. 
Hence with the loss of motion there is a loss of sensation in this 
area. 



NEUROSES OF THE LARYNX. 



797 



1. Paralysis of the External Tensors. 

This affection is extremely rare and seldom is seen except in 
the wake of diphtheria or from some pressure above the trunk of 
the nerve caused by a foreign body or enlarged gland. It may be 
bilateral or unilateral. When examined, the cords, though appar- 
ently in proximation, show a wave-like outline (Fig. 519). 

The chief symptom is a hoarse and uneven voice, lacking power 
and modulation. In unilateral cases the affected cord will have the 
appearance of occupying a higher level than the one upon the 
opposite side. 

Prognosis. — The prognosis is generally favorable. When both 
sensation and motion are impaired or lost there is an added danger 
of pneumonia from the entrance of fluids and solids into the lungs. 

Treatment. — Full doses of strychnine and iron should be ad- 
ministered if due to diphtheria. Mercurials and iodid of potas- 






Fig. 519.— Bilateral pa- 
ralysis of the external 
tensors (cricothyroids). 



# 



Fig. 520. — Complete bi- 
lateral paralysis of the 
supralaryngeal nerve. 



sium are indicated if syphilis.be suspected. Complete rest of the 
vocal organs is of great benefit. Tubal feeding may be resorted to 
in cases wherein the food passes into the larynx. 



2. Paralysis of the Sphincters of the Glottis. 

Careful experiments have confirmed the commonly held view 
that sensation to the larynx above the level of the vocal cords and 
motion to the cricothyroid muscles are both supplied by the superior 
laryngeal nerve and' that the closers of the glottis receive their 
mo'tor supply from the same source. When, therefore, these 
muscles are paralyzed, closure of the glottis during deglutition 
cannot take place ('Fig. 520); consequently, a continuous passage of 
portions of the matter swallowed, principally fluids, into the laryn- 
geal orifice takes place. Inasmuch as the reflex act of coughing 
cannot take place until these foreign substances reach below the 
level of the cords, on account of the anesthesia above them, -"mo 
of these foods enter the trachea, where they an' prone to induce 
pneumonia. 

Treatment. — The treatment is similar to that advised For par- 
alysis of the external tensors. . 



798 THE LARYNX. 

PERVERTED POWER OR SPASMS OF THE LARYNX. 

1. Spasm of the Glottis (Laryngismus Stridulus). 

Etiology. — This affection is largely confined to childhood, being 
more frequent between the ages of three months and two years, but the 
attacks may continue up to the ninth year. It is more prevalent among 
males than females. Opinions differ regarding the primary source of 
the affection as to whether it is central or purely reflex, but it is 
generally agreed that it is found principally among poorly nourished, 
rachitic children. Among the exciting causes are intestinal disorders, 
teething, intestinal worms, adenoids, undue emotional excitement and 
sudden exposure to cold. In short, malnutrition in some form is 
invariably at fault. 

Symptoms. — The symptoms are characteristic and peculiar. 
Absolutely without warning and with no sign of any local disturb- 
ance in the larynx, a child otherwise free from evidences of disease 
of the larynx will suddenly awaken from sleep, sit up in bed and 
manifest all the symptoms of alarming dyspnea of an inspiratory 
character, struggling for breath, sonorous inspiration, and rapidly 
becoming cyanotic. Air will finally enter the lungs and the 
paroxysm terminates in from a few seconds to two minutes. Recovery 
is usually spontaneous, but fatal asphyxia may ensue. The attacks are 
prone to recur and even to increase. 

Diagnosis. — The diagnosis as a rule is not difficult. Apart from 
spasmodic croup, catarrhal laryngitis and an occasional severe 
attack of whooping-cough, all of which are accompanied by cough, 
fever, expectoration and loss of voice, the only disease that simu- 
lates laryngismus stridulus is bilateral abductor paralysis. But the 
paralysis is easily distinguished fro*m spasm, inasmuch as the 
closure of the glottis is constant and incomplete, while in spasm the 
closure is complete but not constant. 

Prognosis. — The prognosis varies in proportion to the gravity 
of the underlying cause. In children who are fairly well nourished 
and who possess a good degree of resistance, in whom the attacks 
are infrequent and show a tendency to diminish in severity, the 
prognosis is good, and it may be expected that the paroxysms will 
finally disappear. 

Treatment. — It is seldom that the surgeon has an opportunity 
to witness a paroxysm of laryngismus stridulus, on account of its 
brevity and irregularity. Hence the mother or nurse should 'be 
instructed to place the child in the sitting posture at the very 
commencement, to loosen the neckbands and to administer a sharp 
slap upon the patient's back. Ammonia may be held to the nose 
and cold water applied to the face and neck. A rapid tracheotomy 
should be performed in cases of threatened asphyxia, providing a 
surgeon can be procured. Mackenzie advocated the administration 
of musk, providing the child is able to swallow, in the following 
formula : — 



799 



ss. 



NEUROSES OF THE LARYNX. 

ft Musk 

White sugar, 

Powdered acacia aa gr. ij. 

Syr. orange flowers ^ xx. 

Water q. s . ad 3j. 

Sig. : Take at one dose. 

The treatment between the attacks must vary in accordance 
with the primary cause and the exciting factors. When the 
paroxysms are frequent it becomes necessary to administer seda- 
tives continuously in order to control them. Bromids, morphia 
and chloral may be administered under proper supervision. The 
mixed bromids are effective. 

ft Bromid of sodium, 

Bromid of potassium aa gr. xx. 

Bromid of ammonium gr. x. 

Syr. simplex 3ij. 

Aquae q. s. ad Sj. 

Sig.: 3j three times a day for a child 1 year old. 

It is important that a healthy state of the upper respiratory 
tract should be maintained. 

The general treatment should be directed to the underlying 
cause or causes of this affection, and usually it involves the adminis- 
tration of remedies for rachitis, viz., cod-liver oil, preparations of 
iron, the hypophosphites and liberal diet, combined with a care- 
fully regulated hygiene, clothing and diet. 

. 2. Spasm of the Glottis in Adults. 

Etiology. — The clinical history of this affection in adults 
presents an altogether different picture than when occurring in 
childhood. For, apart from such attacks as occur as the result of a 
foreign body being impacted in the larynx or the spasms which arise 
from laryngeal edema or new growths, spasm of the glottis in 
adults is seldom dangerous as to life, and is more prevalent among 
females than males. It appears to be purely reflex in its nature, 
although an abnormal excitability of the nervous system must be 
regarded as a predisposing cause. As in childhood, the attack gen- 
erally occurs at night, frequently during sleep, and the patient awakens 
suddenly, seized with a paroxysm of dyspnea, and manifests ;ill the 
symptoms common to spasm of the glottis. Such attacks may be 
repeated, but the regular periodicity so characteristic of thnsr occurring 
in childhood is absent. It is occasionally caused by tabes dorsalis, 
tetanus and hydrophobia. 

Treatment. — The attacks arc usually recovered from before any 
remedial measures have been applied. Inhalations "i" chloroform, 
nitrate of amyl, and ammonia have been recommended. Semon has 
secured good results by advising the patienl to hold the breath for 
two seconds and then to draw two quick inspiration- through the 
nose, with the mouth closed. 



800 THE LARYNX. 

When the disease is caused by new growths and foreign bodies 
in the larynx, the treatment should consist of the surgical removal 
of the obstruction, whenever feasible. 

In case the lesion is central, and in tetanus and hydrophobia, local 
measures are of but little avail, and the treatment should be directed 
to the specific affection in each individual case. Here again it is 
important to maintain a healthy state of the upper respiratory tract. 
This may require operations for the removal of adenoids, hypertrophied 
tonsils, or for the correction of intranasal deformities and diseases. 

When the attacks are functional and therefore of reflex origin it is 
important to institute proper remedial measures, and to sustain the 
patient's general health by proper hygiene, clothing, habits, diet, etc. 

3. Spasms of Co-ordination (Phonatory Spasms). 

In addition to spasms of the glottis which invariably occur in 
the act of inspiration there is a class of these perversions that only 
occurs in the act of expiration ; they are sometimes called expiratory 
spasms. They consist of a loss of power in the co-ordinate control 
of the laryngeal muscles and lead to a spasmodic contraction of the 
glottis in the act of expiration. It is the tensor muscles that are 
primarily at fault, although the adductor muscles are also involved 
in the act. Among these may be mentioned: — 

4. Chorea of the Larynx (Spasmodic Laryngeal Cough). 

The distinguishing feature of this form of spasm is a persistent, 
extremely loud, bark-like cough, so resembling that of the dog 
that children suffering from it are spoken of as "barking children." 
It has also been termed the "barking cough of puberty," and the 
"laryngeal cry." So persistent is this that apart from intervals of 
sometimes only a few minutes, during which the child may act 
perfectly natural, the cough will continue during all waking hours, 
sleep alone affording relief. Between these attacks the voice tone 
remains entirely unchanged, but during the attacks it becomes jerky 
and intermittent. This disease is found principally among girls, 
generally around the years of puberty, and is induced by spasm of 
the adductors, associated with a forcible expiratory movement. 

Treatment. — There is no specific treatment for this affection. 
It is a neurosis, hence the bromids, arsenic, hyoscyamus or can- 
nabis indica may afford relief. It is unwise to give undue impor- 
tance to these patients, for they usually court the notoriety which 
is incited by the peculiar cough. A change of scene in the form of 
a sea voyage, according to Semon, is most effective in terminating 
the attacks. 

5. Dysphonia Spastica. 

This form of spasm differs from "chorea" only in that the 
spasm occurs in an attempt at phonation. For this reason it is 
sometimes called "stammering of the cords." Its prominent charac- 



NEUROSES OF THE LARYNX. 801 

teristic therefore is first an impairment and then a complete loss of 
voice. This is explainable upon the theory that the moment the 
patient attempts to speak the cords come into such absolute apposi- 
tion that the glottis is completely closed and all exit of air for 
phonetic purposes is absolutely cut off. The closure, however, will 
immediately cease the moment the patient ceases his attempts to 
speak, but it recurs just as quickly at every effort to phonate. The 
laryngoscope reveals a healthy appearing larynx in every way, but, 
the moment the cords are brought into approximation and an 
attempt at phonation is made, a spasmodic contraction takes place 
and the glottis closes. Pain has sometimes been complained of 
and is probably due to constriction or cramp. This symptom has 
given rise to the suggestion that the spasm arises from an over or 
strained use of the muscles of phonation, even as writers' cramp is 
caused by an overuse of the muscles of the lower arm. 

Treatment. — There is no specific treatment for this affection. 
Usually the attacks are mild in character and cease after a few days of 
absolute rest of the voice. Whenever the attacks recur the patient 
should be required to take a prolonged rest and if possible a sea voyage, 
to build up his overtaxed and debilitated condition. These measures 
have already been outlined in the previous paragraphs. Likewise, atten- 
tion has been called to the importance of maintaining a healthy state 
of the upper air tract. In some instances it is necessary for the patient 
to adopt a different method of voice production under competent 
instruction. 

6. Laryngeal Vertigo. 

This affection is characterized by a sudden paroxysm of cough, 
which terminates in a loss of consciousness of short duration, during 
which the patient usually falls. It occurs only in adults, usually in 
males and without premonition, leaving the patient as well as before 
the attack and without stupor. Its exact pathology is unknown. A 
case reported by the author 1 gave the following history : — 

W. J. R., aged SO years, an Englishman, manufacturer of confectioners' 
supplies; has resided in America ten years. His family history is good; his 
father and mother are still living and free from neuroses, and live brothers 
are all in good health. His complexion is florid and his appearance robust. 
He has never had venereal disease. He is of nervous temperament, but has 
never developed any neurotic characteristics, but says his friends call him 
excitable. For ten years he has been under severe mental strain From 
business cares. One year ago he had articular rheumatism for four days. 
He has never had muscular rheumatism or gout. Me never has used 
tobacco or snuff in any form, but takes ale cr beer in moderation with his 
meals. 

In July, 1X01, on entering a shop he stepped into an open trapdoorwaj 
and struck on his hip. Me was badly -tunned, but did not lose conscious 
ness. He was in bed eight days, but refer- all hi- suffering t" the hip. and 

says that, although hi' was very nervous, he had no disturbance referable to 
the head and spine during that time. Aside from this he ha- never had any 
fright or sudden -buck of any kind; neither fa- be had convulsions or lit-. 
He has never had vertigo in any Form, but ha- had what he call- bronchial 



i Medical News, March 19, 1892. 



802 



THE LARYNX. 



catarrh for several winters. He has had headaches quite frequently during 
his life, but less so now than formerly, and has never been annoyed by 
hebetude or mental confusion. His attacks of coughing have always been 
accompanied by a profuse discharge of frothy mucus, which was, on one 
occasion, tinged with blood. Physical examination reveals very little except 
coarse rales, but his heart is slightly hypertrophied and its action weak. 

He first came under my notice December 20, 1891. Three weeks 
previously he had taken a cold that had followed about the course of those 
of previous years, until one week ago, when the cough became more violent 
and paroxysmal. He remarked to me that "it was like whooping-cough 
because it was so strangling." Two days before I saw him, during a 
paroxysm of coughing, without premonition of any kind, he fell suddenly to 
the floor upon his back, entirely losing consciousness. The attack lasted 
but a few seconds and he arose from the floor feeling perfectly well, with no 
pain or unpleasant feeling of any kind, and with no vertigo either before or 
following the attack. The sensation was exceedingly pleasurable, and, upon 
being asked how he felt after an attack, exclaimed "I feel as though I had 
been in heaven." 

Following the first attack he had one nearly every day for four days; 
they sometimes occurred while he was in bed. As a rule, he stood up when 
coughing and leaned forward with his hands upon a chair or some other 
object for support, but he invariably fell upon his back during the attack. 
On one occasion he fell upon the street, but was up again before any one 
reached him. In everj- instance the loss of consciousness came on during 
a paroxysm of coughing, but he had many paroxysms of cough which were 
not followed by loss of consciousness. He had had four when I first saw 
him, and loss of consciousness was complete in all. He did not bite his 
tongue, foam at the mouth, or groan or shriek; but on several occasions 
his mouth twitched convulsively during the attack and his eyes remained 
open. He had, in all, twenty attacks and on one day he had five paroxysms 
between 3 and 9 p.m. In every instance there was complete loss of con- 
sciousness. .1 instructed his wife to watch him carefully during the attacks; 
she reported that his face became very blue, and that his attacks terminated 
in from five to fifteen seconds, after which he would arise and walk as 
steadily as before. On two occasions he complained of a sensation of pres- 
sure in the arms and in the region of the deltoid muscle, and, again, of what 
he termed ''smarting of the brain." The patellar reflexes were normal. 

Examination of the upper air passages revealed a general hyperemic 
condition with no specially sensitive areas. There is polypoid degeneration 
of the middle turbinal bones, an exostosis on the septum, on the right side, 
with a posterior hypertrophy on the right inferior turbinal. There is no 
varix at the base of the tongue and only slight hypertrophies. His uvula 
was amputated thirteen years ago on account of its relaxed condition, which 
caused cough. The larynx, aside from a subacute inflammation, is normal 
in appearance. The vocal cords are congested at the edges, but approximate 
perfectly. There are no signs of paralysis. 

After about ten days' treatment the attacks disappeared entirely and 
have not recurred up to this time (February 18, 1892). His diet was carefully 
regulated, his bowels opened with a brisk cathartic, and he was given 15 
grains of bromid of sodium three times a day, in conjunction with S-minim 
capsules of eucalyptol, four times a day. 

Treatment. — Aside from the correction of diseases and abnor- 
malities in the upper air tract, and attention to the general health, 
the internal administration of the bromids in large doses is suffi- 
cient to effect a cure in the majority of cases. Antipyrin in doses 
of 20 to 40 grains has been recommended. 



CHAPTER LII. 

SUSPENSION LARYNGOSCOPY. 

Suspension laryngoscopy is a procedure by means of which 
the curved road from the teeth to the vocal cords can be converted 
into a straight one, so that through the wide open mouth a direct 




Fig. 521. — Complete adjustment of suspension apparatus, with 
strap around head and clamped into ring on hook, to prevent outward 
pressure on teeth and to insure steadiness of instruments. 

view of the larynx can be obtained while the operator is left with 
both hands free for manipulation as the occasion may require. 

The method is not < >nc to be used in routine office work, as a 
means of diagnosis, to supplant indirect laryngoscopy, neither is it 
recommended for every case in which operative or other treatment 
in the region of the larynx is required. Only a well constructed 
instrument should be \\<cd, one made of steel and of sufficienl 
strength to withstand any strain to which it ma\ be subjected. 
The defects which were present in the earlier models have been 
largely overcome, and while to Killian we owe the discovery of sus- 
pension laryngoscopy, il is chiefly to Lynch, of New Orleans, that 
we are indebted for the perfected instrument of today. 

(803) 



804 



THE LARYNX. 



The apparatus as modified by Lynch includes the traveling 
crane (Fig. 521) which may be lowered, or raised, or moved in a 
horizontal direction, and the horizontal bar having notches to sup- 
port the handle of the spatula. The handle is provided with more 
than one hook to give additional latitude in vertical movement. 

The base to which the tongue spatulse (Fig. 522) are attached 
is made especially strong and the body is necessarily heavy to se- 




Fig. 522. — To illustrate the dental spoons (two sizes) and the 
tooth-plates fitting in the horizontal filled-in face. 



cure the large screw for the movement of the mouth-gag in the ver- 
tical direction. 

The mouth-gag, which in the original model could not be 
opened more than an inch in the vertical direction, will now open 
as much as two inches or more, and this amount has so far been 
found by Lynch to be in excess of the widest mouth. 

The ring is pear-shaped and attached at the small end to the 
body, and movement is controlled by a large screw which converts 
the ring into a powerful lever. By turning the screw the spatula 
can be driven to any part of the laryngeal face of the epiglottis and 
by its action tends to elevate the epiglottis, giving a more extensive 
view of the interior of the larynx. 



SUSPENSION LARYNGOSCOPY. 



805 



At the opposite side of the ring- there are two or three tooth- 
plates (Fig-. 522), which are detachable and capable of being 
moved along the bar, so as to distribute the pressure against the 
teeth. To prevent possible injury to the teeth, Lynch has recently 
used with success dental impression spoons which are filled with 
moulding material and made to fit accurately the upper jaw. Two 
sizes are used, one for adults and one for children, designed to fit 
the one set of tooth-plates. 

The table used by Lynch (Fig. 523) is one constructed from 
an old high-low dental base, which will permit the table to be raised 
or lowered twenty inches. The top is of solid hard-wood an inch 




and a half thick, with a projecting platform at the head, to which 
the traveling crane may be attached, thus giving more movement 
in the horizontal direction if necessary. 

The top can be tilted at various angles and moved in a circle 
to take advantage of any light. Foot and shoulder braces are ar 
ranged to secure the patient from slipping. The head-piece is made 
to drop at various angles, so that should the head Fall for an\ reason 
the support would he in place to receive it and prevent a possible 
fracture of the cervical vertebrae. A strap placed around the occiput 
(Fig. 521) and attached at either Side to the pear shaped ring, will 

help to distribute pressure of the tooth-plates against the upper jaw 

and he an additional safeguard in preventing possible injury. 

The patient is placed on the table with the head slightly ex- 
tended and held by an assistant. With the instrument closed, the 
tongue spatula is then introduced into the mouth in the middle line 
and the tooth-plates fixed behind the teeth. The mouth gag is 
opened and the tip of the spatula driven under the epiglottis by 



806 



THE LARYNX. 



means of the screw on the pear-shaped ring. The traveling crane 
is moved into correct position and the spatula hooked over the hori- 
zontal bar (Fig. 521). Extension on the spatula may be produced 
by turning the worm-gear joint on the handle. Moving the crane 
in a horizontal direction, and also vertical, will give additional ex- 
tension and permit a better view of the interior of the larynx. 




Fig. 524. — Introduction of bronchoscope under direct view, 
protecting all parts from traumatism. 



Reflected light from a head mirror is to be preferred, except for 
examination of the trachea, where a light on a carrier or the deep 
tracheal searcher, as it is called, is employed. 

For bronchoscopy and esophagoscopy in infants and young chil- 
dren the head of the table is not dropped as for the regular technique, 
it being more convenient to have the table flat (Fig. 524). Just suf- 
ficient extension, by moving the horizontal crane outwards, is made to 



SUSPENSION LARYNGOSCOPY. 



807 



bring the posterior two-thirds of the larynx into view ; then the neck 
is straightened by the elevation of the traveling crane, and the posterior 
two-thirds of the larynx is brought well into view, in many cases with 
the child's head hardly elevated from the table. 

Without the use of an anaesthetic, which is inadvisable in in- 
fants and young children, the child patient is prepared by being 




Fig. 525.- 



-Demonstrating hook, latter tilted to pati 
right to remove left tooth-plate. 



firmly wrapped in a sheet and the crane so adjusted that flexion ol 
the head rather than extension, may be procured, as the object is 
not to see the anterior commissure but to gain sufficienl room for 
the passage of the tube. 

Then introduce the spatula so that it picks up the laryngeal 
face of the epiglottis and brings into \ iew the interior of the larj n c. 

A solution of 5 per cent, cocain is now applied to the upper pari 
of the larynx only, hem- sure that the trachea receives none of the 



808 



THE LARYNX. 



anaesthetic fluid, on account of the possibilities of diminishing the 
cough reflex, nature's only method of ridding- the bronchial tree of 
excessive secretions. 

The surface of the larynx and vocal cords are next covered 
with sterile vaseline, to permit easy passage of the tube. 

With the larynx thus exposed it is an easy matter to slip the 
bronchoscope or cesophagoscope into their respective openings, 
without traumatizing the part (Fig. 524), separate the cords by the 




Fig. 526. — Hook tilted to left to remove right tooth-plate. 



use of an elevator or retractor, and pass the tube into the trachea 
under direct vision, without its coming into contact with the sub- 
glottic space. Once the tube is past the vocal cords, the manderin 
is removed to establish respiration through the tube. 

If it is probable that the tube will have to be removed and re- 
introduced, as in case of multiple foreign bodies, it will be best tc 
continue the patient in suspension. 

By guiding the bronchoscope through the lumen, one will find 
that it is necessary to flex the head, which can be done by the hori- 
zontal movement of the crane and the worm-gear joint; one is free 
to move the scope laterally because of the extra width of the pear- 
shaped ring. 



SUSPENSION LARYNGOSCOPY. 



809 



By moving the traveling- crane in its various directions the 
tube may be so directed as to permit its accurate passage through 
the bronchus. 

If it is desired to use the tube unaided after its passage through 
the cords, one proceeds as follows : The hook is removed from the 




Fig 527. — Elevation of ring, out of way of bronchoscope. 



crane and carefully tilted to the right (Fig. ?25) to permit the re- 
moval of the left tooth-plate; then the right tooth-plate is removed 
in the same manner ( Fig. 526). The pear-shaped ring is bent 
back upon its hinge and the screw holding the spatula is loosened 
and the body of the hook in this way disengaged From the spatula 
(Fig. ?27 ) ; finally the spatula is removed (Tig. 52X). One then 
attaches the illuminating apparatus and proceeds with his broncho- 
scopy as is usual. 



810 



THE LARYNX. 



Skill in the use of the instrument may be acquired with prac- 
tice, but a certain amount of continuous practice is necessary to 
secure the best results. The operator with, both hands free and 
with the pharynx, mouth of the oesophagus and interior of the 
larynx in direct view (Fig. 529) is in a position to make a more 
thorough examination of the parts than was possible before. The 




Fig. 528. — Removal of spatula. 



inferior surface of the vocal cords can be seen, either by using a 
mirror or by lifting the cords so that the under surface is brought 
into view. A bronchoscope or oesophagoscope may be passed 
directly into the trachea or oesophagus respectively, and lastly, an 
operation can be performed which formerly would not have been 
attempted through the mouth. 

In children especially the method has been used to great ad- 
vantage, enabling the operator to diagnose abnormal conditions in 
the region of the larynx with greater care, and facilitating treatment 
where such is required. 



SUSPENSION LARYNGOSCOPY. 



811 



General anaesthesia is employed in older children, while in 
adults either local or general anaesthesia may be used, depending on 
the disposition of the patient. 

Fixed cervical vertebrae, tumor at the base of the tongue or 



■ 






■•^■1 i a 




ifc^ 




- ^v 


i 


m 



Fig. 529. — Interior of larynx, showing vocal cords in direct view. 



any deformity which would prevent the mouth from being opened, 
or converting the curve from the teeth to the vocal cords into a 
straight line, would be a contraindication to the use of suspension 
laryngoscopy. 



CHAPTER LIU. 

DIRECT LARYNGOSCOPY, TRACHEOSCOPY AND 
BRONCHOSCOPY.! 

History. — As early as 1807 attempts were made to examine the 
esophagus endoscopically. The early attempts were not successful, 
and it was not until 1896 that Mikulicz reported that he had success- 
fully explored the trachea by means of straight tubes. In 1897 
both Kirstein and Killian succeeded in examining- the larynx and 
trachea and the latter succeeded in removing a foreign body from 
a bronchus. Killian then turned his attention to bronchoscopy and 
was finally able to perfect the technique of the direct examination of 
the air passages. In 1902 Einhorn devised an instrument for the 
direct examination of the esophagus, having an auxiliary tube in the 
wall of the main tube for the purpose of carrying a light carrier, which 
places the lamp at the end of the tube. In 1904 Ingals. of Chicago, 
used a separate light carrier in the Killian tube, and in this way suc- 
cessfully removed a pin from the bronchus of a woman. In 1905 Dr. 
Chevalier Jackson, of Pittsburg, perfected an instrument for the pur- 
pose of examining the trachea and bronchi, in which he embodied the 
straight tube of Killian, together with the light carrier devised by 
Einhorn. It is this instrument, with slight modification, which he uses 
to-day, and which will be referred to in the balance of this chapter. 

Within the past two years the direct examination of the air 
passages has made rapid strides throughout America and other 
countries, and many laryngologists are using these tubes with suc- 
cess. For this reason it is fitting that a chapter of this book should 
be devoted to a more or less detailed description of the instruments 
and the technique employed. 

DIRECT LARYNGOSCOPY. 

By direct laryngoscopy is meant the inspection of the larynx 
through a straight tube, in contradistinction to a reflected image on 
a mirror held in the pharynx. The same definition applies to direct 
tracheoscopy and tracheobronchoscopy. Tracheoscopy and tracheo- 
bronchoscopy may be divided into two classes, upper and lower. 
By upper bronchoscopy and tracheoscopy is meant the inspection 
of these structures through a tube inserted by way of the natural 
passages. By lower bronchoscopy is meant an inspection carried 
on through tubes inserted into a tracheotomy wound. 



1 Chapters LIII and LIV are abstracted from Chevalier Jackson's book, 
"Tracheobronchoscopy, Esophagoscopy and Gastroscopy," with his full 
permission and approval. The language is largely that employed by Jack- 
son. The author is also indebted to Dr. Jackson for the use of his excellent 
cuts. 

(812) 



LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 813 

The instruments used at the present time may be divided into 
two classes, according- to whether the light is reflected from a source 
without the tube, or whether it is carried by means of light carriers 
to the end of the tube. As a type of the former class may be taken 
the tubes devised by Killian, which consist primarily of a straight 
tube spatula (Fig. 530), also a split tube spatula (Fig. 531), through 
which secondary tubes (Fig. 532) may be inserted. The best light 
to use in connection with these is that devised by Kirstein (Fig. 
533) and which is worn on the forehead of the operator. Of the 




Fig 



tubes in which a light is carried to 
the distal end by means of a light 
carrier, Jackson's are the most per- 
fect type, and will hereafter be 
referred to in these descriptions. 

They are made of the follow- 
ing- sizes and in conformity with 
the accompanying illustration (Fig. 
534) : 10 mm. by 53 cm. for 
examination of the esophagus of 
adults, and 7 mm. by 45 cm. for 
examination of the esophagus of children, 
should be 7 mm. by 45 cm. for adults, and 5 
children. 

The tubular speculum (Fig. 535) lias heretofore been employed 
for examination and treatment of the larynx, and the separable 
speculum (Fig. 536) for the insertion of the bronchoscope. 2 

The bronchoscopic tubes are made in two styles, one of which 
carries, in addition to the light carrier, a secondary drainage tube 
to which an aspirator may lie attached for the purpose of removing 
excessive secretion or blood from the field of examination. The 
aspirator consists of the ordinary aspirating syringe and bottle con- 
nected with the drainage tube 1>\ means of rubber tubing ( Fig. ?.^7). 



i nc 
mm. 



bronchoscopes 
by 50 cm. For 



2 Dr. Jackson no longer i-mi >!< >\ < tin- tubular speculum, inasmuch 
slide speculum fulfills all requirements. 



814 LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 

In addition to these tubes one must have various forms of 
forceps for the removal of foreign bodies. Those of Jackson (Fig. 
538) and Mosher (Fig. 539) are admirably adapted for the removal 
of foreign bodies and specimens of new growths from the upper air 
passages. One must also be equipped with various hooks, a safety- 




Killian bronchoscopes. 



pin closer (Fig. 540), eye-glasses for the protection of the operator's 
eyes, and about a dozen sponge holders (Fig. 541 ). 

Care must be exercised in the selection of sponge holders in 
order that a model may be obtained which will invariably retain the 
cotton or gauze and prevent any possibility of its becoming detached 
while in the bronchi or trachea. 




Kirstein's headlight. 



One never should attempt to do bronchoscopy without having 
at hand a tracheotomy set, for the reason that it may become neces- 
sary at any time to perform a rapid tracheotomy. 

Extra lamps are also essential. For the purpose of supplying 
light a double storage battery (Fig. 542) is necessary, and com- 
mercial lighting circuits should not be employed for light supply. 
The batteries are equipped with two cords, one of which can be attached 



LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 815 

to the separable speculum while the ,other is attached to the 
bronchoscope, thus obviating the necessity of detaching one cord 
from the speculum and attaching it to the bronchoscope during the 
process of passing the bronchoscope through the speculum. 

Technique. — The first essential in the technique of bronchos- 
copy, as in most modern surgical procedures, is a rigid maintenance 
of asepsis. If time will permit the patient should be prepared by 
free catharsis, the mouth should be carefully cleansed and no 
food should be given for six or eight hours prior to the introduction 
of the tubes in order to prevent vomiting. The patient, the operator 
and all assistants should wear sterile caps and gowns, whether the 
operation be performed in the sitting posture or in dorsal decubitus. 



^=£ 




Fig. 534. — Jackson's bronchoscopy tubes. 



With the exception of batteries, light carriers, cords and the rubber 
portion of the apparatus, the instruments may be boiled. Extra lamps 
should be sterilized in separate tubes by means of dry sterilization. 
The rubber tubing and light carriers may be wiped with a solution of 
carbolic acid or alcohol. The neck should be carefully prepared in 
order to prevent the loss of time should rapid tracheotomy become 
necessary, if during the course of upper bronchoscopy it i- decided to 
do lower bronchoscopy, everything should be resterilized before opening 
the trachea, providing there is time to do this. 

Anesthesia. — For routine office work and the examination of 
adults local anesthesia suffices, but for examination of the larynx 
and trachea of children general anesthesia will usually be necessary. 
General anesthesia will also be required, as ;i rule, for .ill operative 
work on account of the inability of tin' patienl to remain quiel and 
to control the laryngeal reflexes. Chloroform is preferable to ether 
for the reason that it does not cause Mich active secretion of mucus, 



816 LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 

produces less coughing, and causes a quieter narcosis. Atropine, 
y 10 o grain, may be given prior to its administration for the purpose 
of diminishing tracheal secretion. Morphine should not be given, 
because it has a tendency to overcome the slight tracheal and laryn- 
geal reflexes which act as a safeguard to the lungs. Local anes- 
thesia is induced by applications of cocaine. A 4 per cent, solution 




Fig. 535. — Jackson's tubular speculum. 



should first be applied to the pharynx and larynx, 
and 20 per cent, to the trachea and bronchi. 
The application of cocaine to the pharynx and 
larynx is made before the insertion of either of 
the tubes or the separable speculum, preferably 
by means of the Sajous cotton-holding forceps 
(Fig. 543), which prevents the possibility of 
the cotton becoming detached in the larynx. 

After the thorough cocainization of the 
larynx the separable speculum (Fig. 536) is 
introduced, and the further cocainization of 
the trachea and bronchi is carried out by means of small pledgets 
of gauze passed through the separable speculum and bronchoscope, 
on sponge carriers. Cocaine should be used cautiously in children, 
and where it is possible to carry out the examination with a 4 per 
cent, solution this should be done. 



DIRECT LARYNGOSCOPY AND TRACHEOSCOPY WITH THE 
PATIENT IN THE SITTING POSITION. 

Before proceeding to the description of the technique of the 
operation itself too much stress cannot be laid on the necessity of 
adhering to every detail of the position of the patient and assistants 
(Fig. 544) and to the arrangement of instruments. Care should be 
taken to see that the lamps are in perfect working order, and that 
the batteries and cords are properly adjusted. 



LARYNGOSCOPY, TRACHEOSCOPY BRONCHOSCOPY. 



817 



The patient is seated on a low stool, the second assistant being- 
seated on a higher stool directly behind the patient. The instru- 
ment table should be to the patient's left, and the operator should 
stand in front. The first assistant stands to the right of the operator 




Fig. 536. — Jackson's separable speculum for passing bronchoscopes. 

in order that he may be convenient to hand him the instruments 
required, always in a position for insertion. The nurse should 
be stationed behind the instrument table, and it is her duty to 
change the sponges and keep the instruments properly arranged so 
that the first assistant shall have no difficulty in rapidly picking 




Jacks' >n's secretion aspirator. 



them up. The batteries should be placed to the patient's right on a 
stool of convenient height. The duties of the second assistanl are 
extremely important. He musl hold the patient's head benl bark- 
ward, with the trunk, and especially the neck, pushed forward, the 
bend being as much as possible in the region of the axis and 
cervical vertebrae. At the same time he holds the mouth widely 



818 



LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 



open with the gag, and, in the case of the sitting patient, with the 
forefinger he keeps the lips away from the upper teeth. 

The lights having been adjusted to the proper brilliancy, and 
the field having been anesthetized, a separable speculum is inserted 
until the epiglottis appears. In doing this it is not necessary to 
use a mouth gag, the speculum being made of sufficiently heavy 




Fig. 538, 



-Jackson's foreign body forceps and other instruments for the 
removal of foreign bodies. 



material to prevent injury from the patient's teeth. After the 
epiglottis comes into view, the flat end of the speculum is passed 
beyond it about 1 centimeter. And now comes the only point 
where difficulty in the manipulation is encountered. Care must be 
taken not to pass the speculum too deeply, otherwise it will pass 
beyond the larynx into the esophagus. When traction is then made 



Fig. 539/ — Mosher's foreign 
body forceps. 




forward the patient's respiration will be stopped by pressure of 
the end of the speculum on the cricoid cartilage. This accident 
makes itself apparent by the struggles of the patient to obtain air. 
Having passed the flat end of the speculum 1 centimeter over the 
upper end of the epiglottis, this structure and the hyoid bone must 
be drawn forcibly out of the line of vision. This pressure is made 
by the end of the speculum and in doing so care must be taken not 
to use the upper teeth as a fulcrum. A beginner is very liable to 



LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 819 

pass the speculum into the esophageal orifice instead of into the 
larynx, and the bronchoscope may even be passed far into the 
esophagus. This is very frequently followed by a gush of fluid or 
stomach contents. After a little experience one can readily tell by 
the respiratory sounds whether the speculum is in the esophagus 
or in the larynx. When the speculum is properly placed in the 
laryngeal orifice the operator can usually feel the impact of the 
patient's breath against his face. Coughing is frequently a trouble- 
some complication at this time, and unless the operator wears 




Mosher's safety-pin closer. 



glasses to protect his eyes he is liable to have considerable diffi- 
culty. A very clear view of the vocal cords and larynx can now be 
obtained. 

If it is desired to explore the trachea, the tracheoscope, with a 
second cord from the battery attached, is now passed through the 
split tubular speculum beyond the cords and into the trachea. The 
sliding portion of the split speculum is then removed and the handle 
readily comes away, leaving the tracheoscope in position. Instead 
of the tracheoscope a bronchoscope may be inserted in precisely 
the same manner and the bronchi examined. The technique of the 
upper tracheobronchoscopy is illustrated in Fig. 545. Lower 
tracheobronchoscopy may be performed in the same manner, but it 



Fig. 541— Coolidge's sponge holder. (Modified by Jackson.) 

is preferably done in the recumbent position. This is the method 
usually employed in routine office examination and in the removal 
of foreign bodies from the upper air passages, but cannot be suc- 
cessfully carried out in children on account of the struggling and 
inability to control the reflexes. It is not advisable when pro 
longed work is necessary or in the case of nen i ius adults. 

DIRECT LARYNGOSCOPY AND TRACHEOBRONCHOSCOPY, 
DORSAL DECUBITUS. 

In performing this operation in the dorsal position the arrange- 
menl of the assistants and instruments is somewhat different (Fig. 
546). The patient should be placed upon a table, the Eoo1 of which 
is about one foot lower than the head. The second assistant sits 
on a high stool at the head of the table, with his right arm hack 

of the patient's neck, and with his right hand he maintains the 



&20 



LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 



gag- within the patient's mouth. His left hand supports and con- 
trols the patient's head from underneath, the hand resting upon his 
own knee, which is elevated to the proper height by a footstool or 




Fig. 542.— Jackson's improved double-cell batter}', arranged for furnishing 
current to the small lamps which are employed in bronchoscopy. 

by crossing one knee over the other, depending upon the height of 
the table. In this position the second assistant can do his duty 
without undue fatigue during a prolonged search or operation. It 




Fig. 543. — Sajous's cotton-holding forceps for preliminary 
cocainization of the pharynx and larynx. 



is absolutely essential that the second assistant shall make himself 
comfortable, as his work is extremely fatiguing. 

The process of anesthesia, if local anesthesia is used, is precisely 
that described under bronchoscopy in the sitting position. General 



LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 821 




Fig. 544. — Direct laryngoscopy, patient sitting. {Jackson, with permission.) 




1 -Left upper tracheobronchoscopy, patient sitting. 
(Jackson, with permission. » 



822 LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 




Fig. 546. — Left upper tracheobronchoscopy, dorsal position, showing 
the introduction of bronchoscope through the separable speculum. (Jack- 
son, with permission.) 




Fig. 547. — Tracheobronchial tree. LM, Left main bronchus. SL, 
Superior lobe bronchus. ML, Middle lobe bronchus. IL, Inferior lobe 
bronchus. (Jackson, with permission.) 



LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 



823 



anesthesia, however, is, as a rule, more satisfactory, and chloro- 
form should be employed. After the patient has reached complete 
narcosis, this may be administered through a tube inserted into the 
mouth, or from sponge holders saturated and held in front of his nose. 
During the passage of the split tubular speculum it is pref- 
erable that no mouth-gag should be used. The ringer may be used 
as a pilot in order to locate the epiglottis. This, however, is not 
necessary. A separable speculum is passed in precisely the same 
way as described under direct laryngoscopy. After the glottic 




Fig. 548. — Skiagraph of a safety pin imbedded in the larynx. 
(Author's collection.) 

aperture is in view the operator waits until the patient takes a 
deep inspiration, when the cords will be seen to separate, and it it 
is desired to pass the bronchoscope this may be readilj inserted 
between them. For operative work upon the larynx the tubular 
speculum is best adapted. Even when general anesthesia is used 
it is necessary to cocainize the larynx and trachea in order to over 
come the reflexes which are usually present even during the 
administration of general anesthesia. 

Tn inserting the bronchoscope through the split speculum, if 
the double batteries are used both lights should be on and the 
bronchoscope passed between the eords under the direct inspection 
of the eve. If only a single battery is at hand it is advisable, after 



824 LARYNGOSCOPY, TRACHEOSCOPY, BRONCHOSCOPY. 

the split speculum is in place, to detach the cord from it and attach 
it to the bronchoscope and pass it by illumination from this source. 
In case a foreign body obstructs one bronchus care must be taken, 
in passing the bronchoscope into the obstructed bronchus, .not to 
shut off the supply of air to the other bronchi. This can be done 
by so manipulating the bronchoscope that one of the apertures is 
opposite the bronchial orifice. 

LOWER TRACHEOBRONCHOSCOPY. 

Lower tracheobronchoscopy is performed preferably through 
a low tracheotomy, although it may be carried out through a high 
one. It is much more readily done through low tracheotomy, owing 
to the fact that the chin is then further away from the seat of 
operation. Tracheotomy is performed in the ordinary way (Chap- 
ter XXXI), and before attempting to pass any tubes all bleeding must 
be stopped and the trachea thoroughly cocainized. 

In doing this operation it is essential that strict asepsis should 
be carefully observed. The patient should be kept in the Trendelen- 
burg position for some hours afterward. If the operation of lower 
tracheobronchoscopy is satisfactorily accomplished, and there is no 
further use for the tracheotomy wound, it should not be stitched 
completely, but the central portion should be packed with gauze to 
insure perfect and permanent healing by granulation from below. 
During convalescence the wound in the trachea should occasionally 
be inspected by means of upper tracheoscopy. The dimensions of 
the tracheobronchial tree are essentially as follows: — 

Adult Male. Female. Child. Infant. 

Diameter, Trachea • .-. 14x20 mm. 12x16 mm. 8x10 mm. 6 x 7 mm. 

Length, Trachea 12. cm. 10. cm. 6. cm. 4. cm. 

Right Bronchus 2.5 " 2.5 " 2. " 1.5 " 

Left - 5. " 5. " 3. " 2.5 " 

Upper Teeth to Trachea 1.5 " 13. " 10. " 9. 

Total to Secondary Bronchus- 32. " 23. " 19. " 15. 

A semidiagrammatic illustration of the endoscopic appearance 
of the subdivisions of the bronchi is shown in Fig. 547. 

The skiagraph furnishes invaluable information regarding the 
location, size and shape of the foreign bodies lodged in the upper 
respiratory tract and the esophagus. The appearance of a safety 
pin imbedded in the larynx is shown in Fig. 548, 



CHAPTER LIV. 
ESOPHAGOSCOPY. 

For the details regarding the gross anatomy of the esophagus 
the reader is referred to treatises on anatomy. For our purpose it 
is necessary to give only such points as must particularly be borne 
in mind regarding the introduction of ridged, straight tubes into 
and throughout its lumen. 

The variations both in length and the diameter of the lumen 
of the esophagus are so great not only in different individuals, 
but in the same individuals at different times, that it is impractical 
to enter into a detailed discussion of them. It is, however, impor- 
tant in this connection to bear in mind the four points of constric- 
tion in the lumen. The following table (Mosher's complication 
from Stark) furnishes a valuable series of measurements : — 

Diameters of the Esophagus at the Four Constrictions. 

Constriction. Diameter. Vertebra. 

.-. . ., [Transverse 23 mm. (1 in.) ) c . ,, • , 

Cricoid < . . . ■ 17 /./ ■ n > bixtn cervical. 

I Anteroposterior 17 mm. (% in.) J 

. .• [Transverse 24 mm. (1 in.) ) ^ , ., .,, _ . 

Aortlc J Anteroposterior 19 mm. {% in.) \ FoUrth thoracic - 

Left bronchus /Transverse 23 mm. (1 in) j ,.- jf , thoracic< 

( Anteroposterior 17 mm. (Jjj in.) j 

t-»> , f Transverse 23 mm. (1 in.) ) n - .,, tU „ ■ . 

Diaphragm < , , A yi , 1 • \ - 1 cntli tnoracic. 

1 ° \ Anteroposterior 23 mm. (1 in.) J 

The most important constrictions, named in the order of 
importance, are: 1, cricoid (the first from above downward at the 
introitus, opposite the intervertebral disk between the fifth and 
sixth cervical vertebrae); 2, diaphragm (the fourth from above- 
downward, the hiatus, at the exit of the esophagus through the 
diaphragm); 3, aortic (the second from above downward, corre- 
sponding to the arch of the aorta, opposite the fourth thoracic 
vertebra, back of the manubrium of the Sternum), and, 4. left 
bronchus (the third from above downward, o >rresponding to the Kit 

bronchus in front of the esophagus, at the level of the tilth thoracic 
vertebra). 

All of these constrictions are more or less distensible, tin- first, 
or cricoid, being the leasl so. While the extreme elasticity of the 

walF of the esophagus in the normal adult permit- of stretching to 
over two centimetres without rupture, it should he borne in mind 
that rigid tubes and bougies of 'lie Following sizes should pass 
freely, and that failure to pass such instruments should direct the 



826 



ESOPHAGOSCOPY. 



attention to the fact that a stricture, spasmodic or anatomic, 
exists : — 

■d; ,-a +„k / Adults 14 mm. 

Kigid tubes < T r , , . ■, , 

I. lniants and children up to ten... o mm. 

FiexiMe bou^s {f£i ::::::::::::::::::::::::: ^SS 

Esophagoscopy signifies the direct examination of the esophagus 
hy means of tubes introduced through the mouth. The operation 
should he preceded by a thorough and careful examination of the 
upper end of the esophagus. This is accomplished as in direct 
laryngoscopy. 

The pharynx and upper end of the esophagus are cocainized, 
and the tubular speculum passed down behind the tongue, bringing 
the epiglottis into view. After further cocainization of the introitus 
(esophagi the tubular ppeculum is passed onward back of the 
epiglottis, the latter being lifted forward against the base of the 




Fig. 549. — Diagrammatic position of the left hand in starting the 
esophagoscope or gastroscope. (Jackson, with permission.) 



tongue. The arytenoid cartilages are thus observed lying in contact 
with the posterior pharyngeal wall. The spatular end of the specu- 
lum is next inserted into the depression representing the esophageal 
opening, and is passed far enough to reach the arytenoids. By 
lifting forward the cricoid cartilage the upper esophageal lumen is 
seen. The esophagoscope is now passed in the following manner : — 

The patient, prepared as for tracheobronchoscopy, is anesthe- 
tized, preferably with ether, preceded by nitrous oxid gas. 

Montgomery recommends that the patient be placed in the 
horizontal position, with the foot of the table lowered about fifteen 
inches. The patient's neck is bent forward, with the angle as 
nearly as possible at the upper cervical vertebra, in order to 
straighten the oropharyngeal angle, at the same time keeping the 
pharyngeal axis approximately straight. It may be necessary later 
to raise the head in order to prevent tracheal compression. 

The tube, well lubricated with vaselin, is now gently manipu- 
lated, the proximal end being held h>htlv between the fingers 
of the right hand, the handle directed horizontally to the right. 
The left forefinger guides the tube into the right glossoepiglottic 
fossa (Fig. 549) posteriorly to the lateral glossoepiglottic fold, 
posteriorly to the tense pharyngoepiglottic fold, and, if possible, 



ESOPHAGOSCOPY. 



827 



into the right pyriform sinus. The finger then passes toward the 
median line and lifts upward the tongue and anterior pharyngeal 
tissues. 

When the introitus is passed, the obturator is removed and 
the cord attached to the light carrier by the bayonet fitting. The tube 
now being lighted up is passed under the guidance of the eye. Jackson 




Fig. 550. — Position of second assistant and patient for esophago- 
scopy per os. Gowns, caps, and covers are omitted, better to show the 
positions. {Jackson, with permission.) 



calls attention to the following points, which, if observed, render easy 
the passage of the instrument once it is started: 

1. The instrument must have been well greased before 
starting. 

1. The tube musl be guided by the eye so as to Follow the 
c sophageal lumen by sight. 

3. The pinching of the tube h\ the teetli musl be avoided so 
that the tube will be Free to move as needed to Follow the a 
the esophageal lumen as it is seen to open up ahead. 



828 ESOPHAGOSCOPY. 

4. The holding of the head steadily in extreme tension, with 
the mouth widely open ( Fig. 550). 

After the introitus is passed, the head should he slightly raised 
to prevent tracheal compression. 

Only two points will now give the operator any trouble, the 
hiatus diaphragmatis and the bend to the left of the abdominal 
esophagus. 

The fust is passed by placing the long axis of the elliptic cross 
section of the tube from the right posteriorly forward toward the 
left anteriorly. The second is easily passed if the head and neck 
of the patient are moved to the right, and the lumen is carefully 
watched and followed. 

The esophagoscope is extremely useful in skilled hands for the 
detection of disease and subsequent treatment. Stenotic conditions, 
whether due to spasm, cicatricial contractions, new growths in the 
esophagus or mediastinum or other causes, may be diagnosticated 
and surgical or therapeutic measures instituted for their relief, 
through the esophagoscope. 

Diverticula are readily discovered and ulcers located and 
treated. Its most valuable application, however, is in the removal 
of foreign bodies from the esophagus. 



FORMULARY. 
Ear Department, Manhattan Eve and Ear Hospital. 



829 



101 

B 




109 
B 

Hydrarg. Chlor. Corros. 
Tablets Gr.j 


124 

B 




Dropper 




No. 30 


Ung. Hydrarg 


.... 3 j 


102 

b 




no 
B 


126 

B 




Acid. Boric 


.Sij 




Tabl. Sod. Salicyl 

No. 20 


.Gr. v 




103 
B 
Hydrogen. Perox 


..Sj 


in 

b 


127 

B 




b 










Medicine Dropper 

B 

Ear Syringe 




Ac. Boric Gr. xx 

Alcohol (95:0 Sj 


Hydrogen. Peroxldi . . 


. . . . Sj 


Sig. : Ear Drops 


104 

B 




112 

B 


129 

B 




Enzymol 


• s i 


Alcohol (95<) ?.] 


Hydrarg. Bichlor 

Tr. Gent. Comp., 


.Gr.j 
aa Sij 




105 

b 




113 
B 


130 

B 




Emuls. Codliver Oil 




Sat. Sol. Ac. Boric, in 


Hydrarg. Bichlor 

Potassii Iodidi 

Tr. Gent. Comp., 


.Gr.j 

... Sij 

aa Sij 






106 
B 




121 
B 


131 

B 




Ol. Ricini 


.5ij 


Nasal Tab., Seller's xxx 


Sat. Sol. Potass. Iodide 


.....'.j 




107 

B 




122 
B 


132 
B 




Acid. Boric Gr. xx 

Sol. Hydrarg. Blchl., , ,' r,j 

Sp. ViniRect q. s. ad Sj 








n 










Medicine Dropper 




Dobell SJv 


Mist. Rhelet Sndii 


...Siv 


108 




123 

B 


133 

i: 




Tab. Hydrarg. Blchl. ...( 


r. j 








No. 20 










n 




Hydrarg. Oleat., ., 






Mlrt-Rheletitodi] Mv 



830 



Ear 



FORMULARY. 

Department, Manhattan Eye and Ear Hospital. 



134 
Syr. Ferri Iodidi Sj 


143 
Tinct. Iodine 


152 

n 

Ammonii Mur Gr. xx 

Aquae Dest Siv 


135 


144 
Balsam Peru 


153 
Sol. Argenti Nitras.. .Gr. v-3j 




Syr. Simp 5j 

Aquae q. s. ad Siv 


136 
Hydrarg. Bichl Gr. j 


145 

Balsam Peru, 

Ol. Kicini aa Sj 


154 
Sol. Argenti Nitras. ..Gr. x-3j 


Aquae q. S. ad Siv 


137 
Pil.Blaud Gr.iij 


146 
O rthochlorophenol 


155 

B 

Sot. Argenti Nitras.. Gr. 60-3 j 


138 
Pil.Blaud Gr. v 


147 
Ac. Chromic. 


156 

B 

Sol. Argenti Nitras. .Gr.480-3j 


139 


148 
Formalin 


157 

b 

Sol. Adrenalin Chlor. . .1-5000 


Aquae q. s. ad 3j 


141 
Alcohol (9550 


149 
Camphoph< : nique 




14-2 
Ichthyol 


151 

b 

Menth. Cryst., 

Ac. Carbolic. Cryst., 

Cocainae Cryst aa 5j 





FORMULARY. 831 

Throat Department, Manhattan Eye and Ear Hospital. 



201 
Zinc! Oleo-Stearatis. 


Sj 


209 
B 

IOdl.. ;..... 

Zinci Oleo-Stearatis, 
q. 


.Gr. iij 
s. ad Sj 


217 
B 

Acid. Boric 

Lanolin 


1 

....20 


202 

b 

Acetanilidi 

Zinci Oleo-Stearatis, 
a 


...Gr. x 

s. ad Sj 


210 

B 

Liq. Plumb. Subacet. 

Zinci Oleo-Stearatis, 

q. 


....HKx 
s. ad Sj 


218 

B 

Syr.H.I 


...Siv 


203 
B 

Antipyrini 

Zinci Oleo-Stearatis, 

q 


...Gr. x 

s. ad Sj 


211 
B 

Ol. Pini Pumillonis.. . 
Zinci Oleo-Stearatis, 

M. 


....liPx 
s. ad Sj 


219 
B 




Ung. Zinci Oxid 

M. 


...Sij 


204 
B 

Bals. Peruvian! 

Zinci Oleo-Stearatis, 
Q 


.... I1C X 
s. ad Sj 


212 

B 

Ol. Pini Pumilionis. 

Kucalyptol 

Zinci Oleo-Stearatis, 

q 


. aa lip v 
s. ad Sj 


220 

B 

Creosote r 

Ol. Gaulther 


iiii Sij 


Ol. Ricini q. s 


ad Sj 


205 
B 

Emuls. Codliver Oil 


213 

B 

Orthochlorophenol . . 

Zinci Oleo-Stearatis, 

q. 


...njiv 

s. ad 3j 


221 

B 

Nasal Tab., Seller's 


iXX 


206 
B 




214 
B 


..Gr. x 


222 

B 

Dobell 


...Siv 


Zinci Oleo-Stearatis, 

q 


s. ad Sj 




207 

B 

Acidi Carbolic! 

Acidi Boriei 

Zinci Oleo-Stearatis, 
Q. 
M. 


....nrj 

. Jir. x 

s. a.l -.j 


215 

B 

Ung. Hydrargr.Am. . 


.Gr.xv 


223 

B 

Hydrare. Oleat 


.....'•J 


Ung. Aq. Rosa). . ,q. e 


. ad BBS 


208 

B 

< rum Camphor 


. .( ir. iv 


216 
R 


. . . IT vj 


224 
H 

iir.r. Hydrate 


^ 


Zinci Oleo-Stearatis, 

M. 


s. a.l .'.j 


Menthol, 
Camphor... 





832 



FORMULARY. 
Throat Department, Manhattan Eye and Ear HosriTAL. 



225 




233 




241 




Alumnol 

Aquae 

M. 


5j 

Siij 






Ichthyol 

Menthol 

Petrolati 


...Gr.xl 
...Gr.iij 
Sj 


Mist. Rhei et Sodii . 


Siv 


226 




234 




242 




Tabl. Sod. Salicyl... 
No. 20 


. ..Gr. v 






Menthol 

Eucalyptol 


. . . Gr. v 

...111) XV 






227 




235 




243 




Hydrogen Peroxide.. 


Sj 


Ferriet Quin.Cit... 


5iss 


Tr. Iodine 




Syr. Simp 

Aquae q 


Sj 

s. ad Siv 


228 




236 
3 




244 

3 




Aquae Marina 


....Siij 


Hydrarg. Bichl 

Tr. Ferri Chlor 

Aquas q. 


....Gr.j 

Sj 

s. ad Siv 


Aluminum Aoeto Tart 5ss 

Acid. Boric. Pulv Siv 


229 




237 




245 




Hydrarg. Bichlor 

Tr. Gent. Comp., 
Aquae 


...Gr.j 
.aa Sij 


Pil. Blaud 


..Gr. iij 


Alumin. Aceto Tart. 
Aquae Dest 


.Gr. xx 
Sj 


230 




238 




246 

n 




Hydrarg. Bichlor 

Potass. Iod 

Tr. Gent. Comp., 
Aquae 


...Gr.j 
5ij 

.aa Sij 


Pil. Blaud 


...Gr.v 


Menthol 

Eucalyptol 

Vaselin 


.Gr.iss 
.Gr. viij 
Sss 


231 




239 




247 

3 








Adrenalin 

Aquae q 


5 J 

s. ad Sj 


10^ Argyrol 


Siij 




232 




240 




248 
5 




Mist. RheietSodii... 


....Siv 


Ichthyol 

Menthol 

Petrolati 

M. 


. .Gr. xx 

..Gr. iij 
Sj 


20'oArgyrol 


.... Siij 



FORMULARY. 
Throat Department, Manhattan Eye and Ear Hospital. 



833 



249 

Acid. Carbol 

Acid. Tannic 

Glycerini 

Aquae 


Gr. v 

Gr.x 

5iv 

.q. s. ad Sj 


257 

Pulv. Carbo. Ligni 

Kali Bromidi 

Pepsini Puri 

Aqu33 Menth. Pip. 


Gr. v 

Gr.ij 

Gr.j 

Sj 


265 
Sol. Cocaine Mur... 


.... 20^ 


250 

Bororenal 


Sj 


258 

Menthol 

Tr. Benz. Co 


...Gr..xxx 
Siv 


266 
MandellSol 


....no. 1 


251 

Ung. Zinci Oxidi. 

Ung. Hydrargyrl 

Ammonia ti. . . 

Petrolati 




259 
Menthol 


Gr. v 


267 
MandellSol 


no. 2 


Sj 


Milk of Magnesia. 


q. s. ad Sij 


252 

Ammonii Mur 

Aquae Dest 


Gr. xx 

3iv 


260 

Tr. Ferri Chlor . . . 
Glycerini 


Sj 

Sij 


268 
Sol. Argenti Nitras 


.Gr.v-Sj 


253 

B 

Menthol 

Camph. Pulv 


Gr. vj 

. ...Gr. xx 

Sss 


261 

n 

Ichthyol 

Glycerini 


25* 

.q. s. ad Sj 


269 

% 

Sol. Argenti Nitras. 


.Gr. x-3j 




254 

n 

Camph 

Menthol 


Gr. xij 

Gr. x 


262 

Acid. Boric 

Adr. Chlor 

Aquas Rosae 


Gr.x 

.(1-1000) Sj 
.q. s. ad Sj 


270 
Sol, Argenti Nit...( 




Benzoinol 


Sij 


255 
Acid. Carbol 


8ftt.lv 


263 
I* 

Sol. Cocaine Mur. 


& 


271 




M. Sit,'.: Sij in nasal douche. 




256 


264 

n 

Sol. Cocaine Mur 


hi 


272 

n 

Tannin Glycertde, 
Succus Limonls, 
Adrenalin Chloi .. 
Normal Saline Sol., 
To be kepi on 


Ice. 





INDEX. 



Abbe, Robert, 159. 

Abscess, brain, of otitic origin, 374- 
384. 

cerebellar. See Otitic brain abscess. 

cerebral. See Otitic brain abscess. 

epidural, 364. 

extradural, 365. 

laryngeal, 755. 

of auricle, 119. 

of middle turbinals, 549. 

of septum, 545. 

perisinus, 350, 357. 

peritonsillar, 704, 708. 

retropharyngeal, 693. 
Acoumeter, 35, 36. 
Acousma, 54. 
Acoustic neuritis, 391. 

nerve, primary atrophy of, 392. 
Actinomycosis, 480. 
Adam septum forceps, 524, 525. 
Adductor paralysis of lateral cricoary- 
tenoids -and arytenoids, 795. 
Adenoids, 667. 

alterations of voice in, 670, 671. 

anosmia in, 671. 

aprosexia in, 671, 673. 

aural complications in, 672. 

bones and, 670, 671. 

clinical picture of, 669. 

colds, recurrent, and. 672. 

deaf-mutism and, 672. 

diagnosis of, 673. 
by anterior rhinoscopy, 673. 
by digital examination, 673. 
by posterior rhinoscopy, (v?>. 

differential diagnosis, 674. 

disorders of digestion from. 671. 

etiologic significance in ear disease, 
47. 

etiology, 667. 

facial deformity in. 671. 

forceps, Brandegee, 675, 676, 679. 
Hooper, 685. 

hearing in. <>72. 

heredity and, 667. 

inflammatorj symptoms and compli- 
cations nf, 672. 

intranasal inflammations and. ''72. 

lymphatic glands and. 669. 

mentality in, 670, <>73. 

middle ear complications "i. ''72. 

month breathing and. 670. 

nasal obstruction ami. 668. 

neuroses, reflex, induced by, 673. 

operation, 675. 



Adenoids, operation, after-treatment, 
681. 
hemorrhage after, 681. 
position of patient in, 678. 
preparation of patient for, 675. 
with curet, 678. 
with forceps, 679. 
pathology of, 668. 

postnasal, obstructive lesion in naso- 
pharynx, 47. 
prognosis of, 674. 
recurrence after removal, 682. 
respiration in, 670. 
symptomatology, 669. 
treatment, 675. 
Adenomata of pharynx, 738. 
Adhesions, intratympanic, 179, 194, 195. 
in nasopharynx, 681, 682. 
of nasal septum, 545. 
ossilectomy for, 195. 
prevention of, by pneumomassage, 88. 
Aditus ad antrum, anatomy of, 173, 174. 
Air heater, electric. NX. 
Air pressure, negative, in external 

auditory canal. NX. 
Air pump, 88. 
Air, superheated. 87. 
Air-douche hag. Politzer, 19. 
Air-douche therapy, 86. 

Air,, hoi. 48. 

effect upon hearing. 48. 
tinnitus from, 48. 
Alexander, 390. [lum, 535. 

Alleii-I leffermann's submucous specu- 
Allergy in hay fever, 646. 
Allport's mastoid burrs, 283, 284. 

mastoid wound retractor, 231. 
Anders, 472. 
Anemia. 486. 

Anesthesia of larynx, 785. 
Anesthesia, local, in aural surgery, 91. 
cocaine, in submucous resection, 530. 

in radical mast., id operation, "1. 
of pharynx, 743. 
Anesthetic, nitrous oxid, ideal for pai a 

centesis, ''3. 
\neurism, cirsoid, of external ear. 151. 
in thorax and laryngeal paralysis, 

-ISO. 

of an h -I aorta and left lai 

nerve, 486. 
of ascending portion of aorta and 

right reeurr, ni Ian ngeal nerve, 



480. 



i 835 i 



836 



INDEX. 



Aneurism of subclavian artery and 

laryngeal paralysis, 486. 
Angina epiglottidea anterior. See Epi- 
glottis. 
Ludovici's, 755. 
Vincent's, 706, 710. 
Angiomata of external auditory me- 
atus, 164. 

of auricle, 153. 

of larynx, 775, 776. 

of nose, 656. 

of pharynx, 738. 
Angioneurotic edema, 485. 
Ankylosis of cricoarytenoid joint, 773. 
See also Adhesions, intratym- 
panic. 
Annulus tympanicus, 175. 
Anosmia, etiology, 644. 

following influenza, 475. 

in adenoids, 671. 

in chronic hyperplastic rhinitis, 504. 

in frontal sinus disease, 591. 

in maxillary sinus disease, 574. 

obstructive lesions and, 644. 

prognosis of, 644. 

treatment of, 644. 
Anthelix, malformations of, 142. 144. 
Antitoxin, diphtheria, 450, 452, 456. 

dose of, 456. 

syringe, 456. 
Antrum, chisel punch, Myles's, 579. 

curet, Myles's, 583. 

forceps, forward cutting, Ostrum's, 
582. 
Wagner's, 581. 

irrigation tube, Myles's, 579. 

mastoid, anatomy of, 173. 

mastoideum, 173. 

of Highmore. See Maxillary sinus. 

trocar and cannula, Myles's, 577. 
Aphonia, 486. 
Applicator, angular flat, 552. 

concealed, Tuerck's, 768. 

laryngeal, Phillips's, 665, 767. 

platinum, 12. 
Aprosexia in adenoids, 671, 673. 

in frontal sinus disease, 591. 

in maxillary sinus disease. 574. 
Arrowsmith, concerning Vincent's an- 
gina, 710, 711. 
Arteriosclerosis, effects of high blood- 
pressure in, 486. 
Asch operation for deformity of sep- 
tum, 527. 

scissors, 526. 

septum forceps, 527. 
Aspirator, Jackson's secretion, 817. 
Asthma, 484, 649. 

etiology, 484. 

Sajous's theory concerning, 484. 
Asymmetry of pharynx, 688, 689. 
Atiieromata of external ear, 152. 



Atresia of external auditory canal, 139. 
Atrophic laryngitis, 770. 

pharyngitis, 719. 

rhinitis, 440, 508. 
Attic, 173. 
Auditory canal, external, 26. 

hallucinations. See Acousma. 
Aural discharge (see Otorrhea), from 
tympanic cavity, 59. 
from walls of external auditory 

canal, 59. 
symptoms of diseases and injuries 
of external auditory meatus, 
59. 

speculum, how to introduce, 10. See 
also Speculum. 
Auricle, angiomata of, 153. 

anomalies of, 143. 

cystomata of, 153. 

cysts of, sebaceous, 152. 

epitheliomata of, 155. 

Ibromata of, 151. 

function of, 25. 

horny growths of, 151. 

keloid of, 151. 

landmarks of, 104. 

lupus of, 412. 

malformations of, 143. 

papillomata of, 151. 

perichondritis of, 120. 

sarcomata of, 159. 

supernumerary, 142. 146. 

surgical anatomy of, 103. 

variations in, 103. 
Auscultation of middle ear, 67. 
Autoinsufflation, Leduc, 430. 
Autophonv, 53, 187, 200. 
Avellis, 789. 

Bacon, 436. 

scarifier and cupping glass, 97. 
Bacteremia, 41, 74, 351. 
Bacteria in middle-ear discharge, 41. 

mode of entrance into tympanic cav- 
ity, 42, 43. 
Bainbridge's test of enzyme treatment 

for cancer, 659. 
Ballance flap, 297. 
Ballenger, 135, 307, 414, 618, 725, 726. 

forceps, bone-cutting, 534. 

mucosa knife, 530. 

perichondrium elevator, 531. 

swivel knife, 533, 535. 
Baranv noise producer, 338. 

tests, 30. 
Baratoux, 436. 
Barie, 489. 

Barker, life insurance statistics, 398. 
Barnhill, 113, 372. 
Barnick, 43. 
Basserau, 436. 
Battery, Jackson, 820. 



INDEX. 



837 



Bayer, 574, 710. 

Beck, 91, 98, 480. 

Beckman adenoid curet, 675. 

Beckman-Rienecke, 75. 

Belocq sound for treating epistaxis, 

641. 
Benzoinol, O. B. Douglass formula for, 

496. 
Berens, 78. 

spokeshave, 563. 
Berkley, 432. 
Bettmann, 489. 

Bezold, 36. 37, 130, 167. 170. 181, 213, 
217, 220, 221, 269, 287, 329, 336, 
337, 338, 386, 409, 419, 457. 
Bezold's theory of etiology of middle- 
ear catarrh, 181. 
Bezold-Edelmann, 37. 
Bib for patients, 6, 7. 
Bier, 97, 98. 

method of inducing hyperemia, S3, 
221. 
contraindications, 98. 
indications for, in aural disease, 
97, 98. 
Billroth, 368. 
Bing's hearing test, 40. 
Birkner, life insurance statistics, 398. 
Bistoury for incising peritonsillar ab- 
scess, 708. 
Blake, 247, 272. 
Blau, 514. 
Blennorrhea, chronic. See Rhinitis, 

simple chronic. 
Blood-clot method of closing mastoid 

wound, 247. 
Blood-count, 75. 
differential, 76. 
Blood-cultures, 76. 

examinations, value of, in otologv, 

74-79. 
significance of, 77. 
Blood-pressure, influence of, on dis- 
eases of ear, nose and throat, 
486. 
in suspected intracranial complica- 
tions of suppurative car dis- 
eases, 102. 
Bloodletting, local. 96, 97. 

Bacon's scarifier and cupping glass 

for, 97. 
in acute infectious laryngitis, 7?7. 
in acute inflammation of ethmoidal 

sinuses, 612. 
in acute peritonsillitis, 709. 
Boenhaupt, 657. 

Boenninghaus, 181, 184, 214, jyx 25". 
1,2 27H. 331, 332, 335, 342, 346, 
34S, 34<>, 350, 355. 367, 368, 374. 
376, 377, 386, 388, 390. 
Boisseau. 403. 
Bordes, A., 409. 



Bosworth, 510, 515, 516, 778. 

formula for codeine, 753. 

nasal saw, 541. 
speculum, 11. 
Bougie, Duel electric, 194. 

Eustachian, 21, 22. 
dangers of, 22. 
method of passing, 21. 
Bowman's eve probe in mastoid opera- 
tion, 236. 
Brain, abscess of, otitic origin, 374-384. 

after-treatment, 3S3. 

course, 376. 

duration, 379. 

etiology, 374. 

pathology, 375. 

prognosis, 379. 

symptoms, 376. 

treatment, operative, 380. 
results, 384. 
technique, 383. 
Brandegee adenoid forceps, (>75, 676, 

"679. __ 
Braunstein, 71. 
Bricy, 70. 
Brieger, 182. 
Briezer, 368. 
Broeckart, 515. 
Bronchoscope, Kill ian. 814. 
Bronchoscopy, direct, 812. 

history of, 812. 

lower. 812. See nls<> Tracheobron- 
choscopy tubes, |acksoii's. 
Bruce. II. \\\. 706. 
Bruger, 352. 
Bruhl, 254. 

Briining's forceps, 553, 616, 619. 
Bryant, 307. 
Bulkley, 436. 
Bulla ethmoidalis, 567, 5S7. 

frontalis, 587. 
Burckhardt, 4' 7. 
Burkner, 345. 
Burnay's sponge, 641. 
Butlin's technique for thyrotomy, 7*-. 

( '.il.niet For electric s\\ itchboard, 6. 

for instruments, 3. 
Caboche, 414, 415. 417. 
( aiger, 467. 

i laisson worl ! e, 391. 

Calcareous deposits in membrana tym- 

pani, 66, 189, 1"". 
Caldwell, 5S4. ~^>>2. 
Caldwell I. M. .'i- ration for maxillary 

shins disea 
t 'alinettc ophthalmic n action in tuber 

culosis of ear, nose, and throat, 

4i is, 409 
< lampbell, 115. 

( 'anine fossa, operation through, 581. 
i annnl.i. intratracheal, 7^2. 
i .,,-. inomata of larynx, 77*. 



838 



INDEX. 



Carcinomata of nose, 659. 

of pharynx, 740. 
Caries of external auditory canal, 140. 
etiology of, 140. 

in chronic purulent otitis media, 256. 
treatment, 141. 
Carotid artery, in jury to, in radical 

mastoid operation, 289. 
Carter, description of paraffin injection, 
635, 638.- 
splint, bridge and nasal, 636. 
tonsil tenaculum, 725, 726. 
Casselberry method of feeding after 

intubation, 464. 
( "astaignes, 70. 

Catarrh, acute middle-ear, 181. 
course, 183. 
diagnosis, 184. 
etiology, 181. 
life insurance and, 400. 
pathology, 181. 
prognosis, 185. 
treatment, 185. 
autumnal. Sec Rhinitis, hyperes- 

thetic. 
chronic middle-car, 186. 
diagnosis, 192. 

differential, 192. 
etiology, 186. 

functional tests for hearing in, 191. 
life insurance and, 400. 
otomassage in, 194. 
otoscopic picture in, 188. 
pathology of, 186. 
prognosis of, 192. 
symptomatology of, 187. 
treatment of, 188. 
chronic nasal. See Rhinitis, simple 

chronic, 
hypertrophic nasal. See Rhinitis, 

chronic hyperplastic, 
nasopharyngeal. See Nasopharyn- 
gitis, 
postnasal, chronic. Sec Nasopharyn- 
gitis. 
purulent nasal. See Rhinitis, chronic 
purulent. 
Catarrhal laryngitis. See Laryngitis, 
simple, 
pharyngitis. See Pharyngitis, simple, 
tonsillitis. Sec Tonsillitis, simple. 
Catheter, Eustachian, 17. 

diagnostic value of, 17. 
faulty position of, 20. 
intratympanic medication bv means 

of, 86. 
methods of passing, 16-19. 
Catheterization, Eustachian, 17. 
method of, 19. 
obstacles to, 20. 
position of patient during, 18, 
"Cauliflower ear," 56, 



Cerebellar abscess. Sec Otitic brain 

abscess. 
Cerebral abscess. Sec Otitic brain 

abscess. 
Cerebrospinal fluid, bacteriological find- 
ings in, 69. 
color of, 69. 
cytodiagnosis of, 70. 
differential diagnosis and, 71. 
examination of, 69. 
pressure of, 69. 

significance of pathological find- 
ings in, 70. 
Cerumen, impacted. 130. 
diagnosis of, 132. 
etiology of, 131. 

hearing tests before removal of. 133. 
legal aspects of, 133. 
pathology, 131. 
prognosis, 132. 
removal by douching, 80. 
symptomatology of, 131. 
treatment for, 133. 
Chair, revolving, 1. 
Chancre, of larynx, 437. 
of mouth, 437. 
of nose, 436. 
of pharynx, 437. 
Chapin's tongue depressor, 13, 674 
Charcot, 53. 
Chavasse, 70. 
Cheatle, 475. 
Chimani, 154, 403. 

Chimani-Moos test iri simulated deaf- 
ness, 402. 
Chisels, for mastoid operation, 236. 
antrum punch, Myles's, 579. 
Killian's V-shaped, 002, 603. 
Choanse, 661, 662. 

Cholesteatomata, in acute purulent 
otitis media, 245. 
in chronic purulent otitis media, 255. 
of temporal bone, 166. 
Chondritis of larynx, 772. 
Chondromata of larynx', 775, 776. 
Chorditis nodosa, 769. 
. etiology, 769. 
pathology. 769. 
prognosis, 770. 
symptoms, 769. 
treatment, 770. 
tuberosa, 769. 
Chorea, of larynx, 800. 

pharyngeal, 742. 
Circulatory system, influence of dis- 
eases of, on ear, nose and 
throat. 486. 
Cirsoid aneurysm of external ear, 154. 
Citelli, 390. 

Clergyman's sore throat, 716. See 
Pharyngitis, chronic granular, 
Coakley, 445," 521, 592. 



INDEX. 



839 



Coakley transillumination lamp, 575, 

576. 
Cocaine in aural surgery, 91, 92. 

in radical mastoid operation, 91. 
Cochlea, 29, 30. 
Coffin ring adenoid curet, 676, 677. 

suction apparatus, 577, 578. 
Cold, influence of, in aural inflamma- 
tion, 47. 
Coley, 659. 

Compressed-air apparatus, 5. 
Coolidge's sponge holder, 819. 
Corbett, 470. 

Corning, on lumbar puncture, 69. 
Corti, cells of, 30. 

organ of, 31. 
Coryza. See Rhinitis, vasomotor ; also 

Rhinitis, hyperesthetic. 
Cotton applicator, Phillips's, 665. 

holder, Phillips's, 7. 
Cough in tuberculosis of larynx, 424. 
Coyon, 477. 
Craiger, 476. 
Crista acoustica, 31, 32. 
Croup kettle, 761. 

membranous, 759. See Laryngitis, 
membranous. 

spasmodic, 748. See Laryngitis, sim- 
ple acute. 
Croupous laryngitis. Sec Membranous 

laryngitis. 
Curet, adenoid, Beckman, 675, 677. 
Coffin, 676, 677. 
protractor for, Thomson, 678. 
Stubbs, 676, 677. 

angular, 277. 

antrum, Myles's, 583. 

Eustachian, Neumann, 284. 

pharyngeal, Myles's, 718.' 

Richards, 284. 

ring, 277. 

septal, Yankauer, 531, 532. 
Curtis. 648, 770. 
( 'uspidor, fountain, 3. 
Cystomata of external car. 153. 

of larynx, 775, 77<>. 

of middle turbinate, 549, 550. 
Cysts, sebaceous, of external ear, 152. 

Da Costa, 76. 
Day, 91, 472. 

Deaf-mutism, 50, 395. See al 
ness, total. 

acute infectious diseases and, 395. 

adenoids and, 395, 672. 

consanguinity and. 3 ( >5. 

diagnosis ol 

etiology of, 395. 

from chronic purulenl "litis media, 
260. 

from scarlatina, 467. 

heredity and, 395. 



Deaf-mutism, intracranial inflamma- 
tions and, 395. 
lip-reading in, 396. 
otologists and, 398. 
prognosis of, 396. 
schools for, 396. 
treatment, 396. 
Deafness, acoustic neuritis and, 391. 
boilermakers', 53, 187. 
causes of, 48. 
hysterical, 404. 
idiopathic total, 50. 
intermittent, 52. 
from adenoids, 395, 672. 
in leukemia, 4S7. 
in tabes dorsalis, 488. 
labyrinthine, from caisson work, 48. 
partial, 51. 
postprandial, 52. 
psychical, 390. 
scarlatinal, 467. 
senile, 51. 
simulated, 401. 
symptomatic total, 50. 
Deaver, 663, 746, 747, 751. 
Deflections of septum. 520. 
Deformities, external nasal. 629. 

correction of, 631. 
Delstanche masseur, 388. 
pneumatic speculum, 23. 
rare factor, 88. 
Dench, 42 74. 95, 271, 300, 307, 345. 
life-insurance statistics, 39S. 
middle-ear vaporizer, 18, 20, 87. 
Denhart's mouth-gag, 674. 
I >enker, 385. 
Desault, 581. 
i »e Simoni, 480. 

Deviations of nasal septum, 520. 
I >e Vilhiss atomizer, hand. 4. 

spray, 496, 497. 
I Jieffenbach's operation for sarcoma of 

nose, 658. 
Dietl, 368. 
Digestive system and diseases of upper 

respiratory tract, 482 484. 
I (ilatation of pharynx, 688. 
Diphtheria. 449. 
antitoxin in, 450, 452, 455. 
etiologj of, 149 
extubation in, 465, 
intubation 

ini.1.11' car suppuration in, 451. 
mode of infection, 449 
of ear, 451. 

of larynx, 453. 

of nose, 452 
of pharj nx, 453. 
pathology, 450. 
prognosis, 454. 
sequ< I 
symptoms, 451. : 



840 



IXDEX. 



Diphtheria, tracheotomy in, 465. 
treatment of, 454. 
antitoxin, 455, 456. 
constitutional, 455. 
dietetic, 455. 
hygienic, 455. 
local, 457. 
prophylactic, 454. 
types of, 450. 
Diplacusis, 53. 

in syphilis of internal ear, 435. 
Direct laryngoscopy, 14, 812, 816, 819, 

821. 
Diverticula of pharynx, 688. 
Dixon, 42. 

Domoehowsky, 571, 572. 
Douche, ear, 80. 
Douglas, 99. 
douche-hag, 538. 
periosteal elevator, 229. 
Douglas, O. B., formula for benzoinol, 

496. 
Downie, 333, 467, 469. 
Drainage tube, Ingals, 599. 
Drum membrane. See Membrana tym- 

pani. 
Duchenne, 488. 

Duel, 22, 78,311,351,451,467. 
electric bougie. 194. 
operation for "lop-ear," 147. 
Dumond, 423. 

Dunbar's serum for hay fever, 485, 649. 
Dunning, William M., 242, 330. 
Dura, injury to, in radical mastoid 

operation, 287. 
Dust, behavior of, in tonsillar crypts, 
Wright's experiments with, 702. 
Dwyer, 100, 120, 646. 
Dysacousia, 187. 

Dysphagia, in congenital tertiary syph- 
ilis, 447. 
in hydrophobia, 478. 
in tuberculosis, 424, 429. 
Dysphonia spastica, 800. 
Dyspnea in syphilis of larynx, 423, 430. 
in tuberculosis of larynx, 443, 447. 

Ear, anatomy of, 103, 173. 

cough, 60. 

examination of, functional, 10. 
physical, 34. 

external, 103. 

internal, 29, 312. 

life insurance and diseases of, 398. 

middle, 173. 

speculum, 23, 24, 93. 
Earache, in acute purulent otitis media, 

200. 
Eardrops, purposes of, 90. 
Eburnation. See Sclerosis. 
Eczema of external ear, 108. 

acute, 109, 



Eczema, chronic, 110. 

intertrigo, 108. 
Edema, angioneurotic, 485. 

in tertiary syphilis of larynx, 446, 

447. 
in tuberculosis of larynx, 423. 
of larynx of cardiac origin, 486. 
subglottic, 423. 
Ehrlich's arsenical preparation, "606," 

for syphilis, 432. 
Einhorn light carrier, 812. 
Electric air heater, 88. 
bougie, Duel, 22. 
ear speculum, 93. 
motor, 6. 
Electromotor air-pump, 88. 
Emboli in brain following thrombi in 

carotids, 393. 
Empyema of antrum of Highmore, 572. 
of ethmoidal sinuses, 612. 
of frontal sinus, 589, 596. 
of sphenoidal sinuses, 624. 
suction treatment in chronic, 577. 
Enchondromata of external auditory 
meatus, 161. 
of nose, 656. 
Environment, influence on auditory ap- 
paratus, 47, 48. 
Enzyme treatment, Bainbridge's test of, 

in cancer, 659. 
Epiglottitis, acute infectious, 746. 
Epilepsy improved by removal of nasal 
polypi, 650, 652. 
of nasal orgin, 650. 
spasms of pharynx in, 742. 
Epistaxis, 639. 
diagnosis of, 640. 
etiology of, 639. 
sound for, Belocq, 641. 
treatment of, general, 641. 
local, 640. 
Epitheliomata of external auditory me- 
atus, 165. 
of external ear, 155. 
Epitympanic space, 67, 173. 
Erb, 448. 
Erhard's test in simulated deafness, 

402. 
Erysipelas, from otological standpoint, 
119. 
of ear, 476. 
of larynx, 477. 
of nose, 476. 
of pharynx, 476. 
special treatment of, 120. 
Escat, concerning lupoid character of 

tuberculosis, 414. 
Esophagoscope, 826, 828. 
Esophagoscopy, 825, 827. 
Esophagus, anatomical points, 825. 
Ethmoidal sinuses, anatomy of, 609. 
inflammation of, acute, 610. 



INDEX. 



841 



Ethmoidal sinuses, inflammation of, 
acute, diagnosis, 611. 
etiology, 610. 
pathology, 610. 
symptoms, 611. 
treatment, 611. 
inflammation of, chronic. See 
Purulent ethmoiditis. 
Ethmoiditis, chronic purulent, 612. 
course, 613. 
diagnosis, 615. 
etiology, 612. 
pathology, 612. 
prognosis, 615. 
symptoms, 613. 
treatment, 577, 616. 
after-treatment, 620. 
complete removal of cells by intra- 
nasal route, 616. 
complications of, 618. 
complete removal by external route, 

619. 
partial excavation by intranasal 
route, 616. 
Ethyl chlorid as local anesthetic in 

aural surgery, 92. 
Equilibrium, disturbances of, 312. 
Eustachian bougie, 21. 
catheter, 16, 17. 
tube, anatomy of, 173, 176. 
catheterization of, 16-22. 
foreign bodies in, 138. 
function of, 27, 176. 
new growths in, 165. 
obstruction of, 67. 
ossification of membranous portion 
of, 177. 
Ewald's experiment, 315. 
Examination of patients, 8-23. 
Exostoses of external auditory meatus, 
161. 
causes of, 161, 162. 
diagnosis, 162. 
prognosis, 162. 
treatment, 163. 
External auditory meatus, anatomy of, 
61, 104. 
atresia of, 139. 
blood-supply of, 107. 
caries of, 140. 
development of, 105, 106. 
diseases of, 124. 
foreign bodies in, 134. 
hemorrhage of, 141. 
in children, 61. 
integument of, 107. 
lymph supply of, 107. 
negative air-pressure in, 88. 
nerve supply of, 107. 
pain in, 56. 
peculiarities in, 61. 
plastic surgery of, 290. 



External auditory meatus, relation of, 
to mastoid antrum, 107. 
sterilization of, 82. 
tumors of, benign, 161. 
malignant, 140, 155. 
External ear, anatomy of, 103-107. 
anomalies of, 142. 
diseases of, 108-166. 
malformations of, 142. 
wounds of, 119. 
Extubation in diphtheria, 463-465. 

Facial deformity, in adenoids, 671. 
in labyrinthine disease, 338. 
nerve, injury to, in mastoid opera- 
tion, 285. 
paralysis, of otitic origin, 309, 338. 
False nose, 640. 
Fauces, anatomy of, 686. 

examination of, 14. 
Faucial tonsils, removal of, 730. 
Faught, blood-pressure apparatus, 486.^ 
Fenestra ovalis, 174. 

rotunda, 174. 
Fibrolysin in chronic middle-ear ca- 
tarrh, 195. 
Fibromata of auricle, 151. 
of larynx, 775. 
of nasopharynx, 683. 
of nose, 665. 
Fibromyomata of larynx, 775. 
Finkelstein, 476. 
Finlavson, 467. 
Fischer, 72. 467. 

method of extubation illustrated, 463, 

464. 
method of intubation illustrated, 457, 
459, 460, 461. 
Fistula congenita auris, 145, 149. 

test in purulent labyrinthitis, 325. 
Fleiss, 489. 
Floyd, 100. 

Forceps, adenoid, Brandegee, 675, 676, 
679. 
Hooper, 685. 1 582. 

antrum, Ostrum's forward-cutting, 

Wagner's forward-cutting, 581. 
bone-cutting, 536. 
Bruning's, 553, 604, 616, 619. 
chisel, Kerrison, 278. 
cotton-holding, Sajous's, 816, 820. 
foreign-body, fackson, 818, 

Mosher, 818. 
hemostatic, Rosenheim, "_'<>. 731. 
Killian, 428, 599. 
laryngeal, Frankel, 770. 
Grant, 770. 
Krause, 770. 
Kr.uise I lerzog, 427. 
Scheinmann, 770, 
punch, < iriinwald's, 551, $$-■ 
ur, 239, 240, 



842 



INDEX. 



Forceps, septum, Adam, 524, 525. 
Asch, 527. 
Roe, 525. 
sinus, Lester's, 709. 
sphenoidal, Griinwald, 627. 
tenaculum, Thomson, 724. 
Fordyce, John A., 411, 415, 417, 422, 

433, 437. 
Foreign bodies, in ear, 134. 
diagnosis, 135, 642. 
etiology, 134. 
in Eustachian tube, 138. 
in middle ear, 138. 
in nose, 642. 
symptoms, 135, 642. 
treatment, 135, 642. 
insects, 135. 

inanimate objects, 136, 642. 
Formulary, 829-833. (Manhattan Eye, 

Ear, and Throat Hospital. ) 
Fornix, 661. 

Fossa of Rosemuller, 661. 
Foster, 643. 
Founder, 436. 
Fowler's experiment, 28. 
hearing test, 40. 
infection apparatus, 29. 
nasal douche, 512. 
resonator apparatus, 40. 
suction apparatus, 80, 81. 
Fox, 417. 
Francis, 484. 
Frankel, 574. 

laryngeal forceps, 770. 
Frankenberger, 672. 
Frazier, 309, 311. 

Freer's modification of submucous re- 
section, 535. 
perichondrium elevator, 531. 
Freudenthal, 489. 

Friederich, 73. 329, 334, 337, 33S, 392. 
Frigario, 143. 
Frontal sinus, 587. 
anatomy of, 587. 
diseases of, 588. 

inflammation of, simple catarrhal, 
588. 
diagnosis. 589. 
etiology, 588. 
prognosis, 589. 
treatment, 589. 
purulent, 589. 
diagnosis, 591. 
etiology, 589. 
pathology, 590. 
symptoms, 590. 
transillumination in, 592. 
treatment, 595. 
operations upon, in chronic empy- 
ema, 596. 
Killian, 601. 
Kuhnt, 600, 



FYontal sinus, operations upon, Luc, 
600. 
Ogston-Luc, 600. 
radical, 598, 606. 

difficulties and dangers of, 607. 
second, 608. 
periostitis, 595. 
diagnosis, 595. 
prognosis, 595. 
treatment, 595. 
treatment, 596. 
intranasal, 596. 
Frostbite of auricle, 47. 
Fungi in nose, 643. 
Funk, 43. 

Furunculosis of external auditory me- 
atus, 124. 
of nose, 643. 

Gallagher, 428. 

Galton whistle, 37, 38. 

Galvanocautery, for destruction of tur- 
binal hyperplasia, 560. 
for removal of neoplasms of pharynx, 

738. 
knife, Phillips, 683. 

Gangrene of external ear, 118. 

Gaucher, 446. 

Gelle's hearing test, 40. 

Genital system, disturbances of, in re- 
lation to diseases of ear, nose 
and throat, 489. 

Gerber, 284, 337, 478. 

Gerlach, 177. 

Gersuny, paraffin injection method, 632. 

Glanders, 479. 

Gleason, operation for deformity of 
nasal septum, 525, 526. 

Glenard's disease and nasopharyngitis, 
483. 

Glenoid fossa, injury to, in radical mas- 
toid operation, 290. 

Globus hystericus, 742. 

Glottis, spasm of. in adults, 798. 
in children, 799. 

Goldstein, 143, 144, 145, 148. 150, 643. 
operation for "lop-ear," 147. 

for macrotia, 147. 
plastic flap, for perforation of nasal 
septum, 543. 

Goodale, 701, 702. 

Gottheil, 478. 

Gottstein, 474. 

Gout, 480. 

Gradenigo, 200, 338, 412, 434. 

Grant's laryngeal forceps, 770, 771. 

Granulomata in mastoid cells and an- 
trum, 165. 

Grayson, 548. 

Green, 488. 

Grey, 91. 

Griesinger sign, 350. 



INDEX. 



843 



Groeber, 75. 
Grossman, 238, 307. 
Gruber, 116, 272, 345. 

life-insurance statistics, 398. 
Gruening, 78. 
Griinert, 307, 365. 
Griinwald, 407, 418, 618, 628. 

punch forceps, 551, 552, 614, 618. 
Gummata, 439. See also Tertiary syph- 
ilis. 

of ear, 434. 

of larynx, 439, 442, 445. 

of mouth, 439. 

of nose, 439, 444. 

of pharvnx, 439, 441, 445. 
Guntzer, 478, 479. 
Gurich, 477. 

Haberman, 334, 335, 390. 

Hahn's tracheotomy tube, 782. 

Hajek, 413, 566, 568, 570, 572, 590, 601, 

613, 616, 622, 624, 746. 
Halle's frontal sinus burrs, 597, 598. 
Harris, 355. 

Hartman silver probe, 67. 
Hartmann probe for exploring tym- 
panum, 263. 
tuning forks, 37. 
Hartz, H. J., 386. 
Hasslauer, 370. 
Hassler, 345. 

Hay fever, 645. See Rhinitis, hyperes- 
thetic. 
allergy and pollen-therapy in, 646. 
inoculation in, 647. 
Hays laryngoscope, 755. 

pharyngoscope, 15, 664, 75j, 756. 
Hayem, 75. 
Head. 115. 
Headlight, 4. 
Kierstein's, 14. 
Phillips's, 4. 
Head mirror, 4. 

Hearing disturbances of, of intracranial 
origin, 395. 
in malaria, 47X. 

in Meniere's symptom-complex in 
otitis media, chronic purulent, 
266. 
influence of drugs and narcotics on, 

48. 
influence of radical mastoid opera- 
tion on, 306. 
physiology of, 24-33. 
requirements of army and navy re 

garding, 403. 
schools for children with defective, 

397. 
tests for, acoumeter, 35. 
Bing, 40. 
Fowler, 40. 
Rinne, 39. 



Hearing, tests for, Schwabach, 38. 
tuning-fork, 34. 
voice, 34. 
watch, 34. 
Weber, 39. 
Heath, 307. 

frontal sinus probe, 591. 
Heine, 221, 284, 339, 349, 369. 
Heinrich, 480. 
Heinze, 422. 
Held, 347, 370, 706. 
Helix, malformations of, 142, 144. 
Helmholtz, 26, 27, 29, 31, 32. 

theory of sound, 30. 
Hematoma of septum, 544. 
Hemilaryngectomy. See Partial laryn- 
gectomy. 
Hemorrhage, in congenital nevus, 154. 

laryngeal, 429. 
Hemostat, Hurd's tonsil, 731. 

Miculicz-Stoerck, 727. 732. 

Rosenheim's, 726, 731. 
Henle, spine of, 229, 230. 
Henrici, 480. 

Heredity, influence of, on auditory ap- 
paratus, 47, 48. 
Herpes zoster of external ear, 114- lid. 
Heryng, 575. 
Herzog, 426. 
Hess, 368. 
Heterotophy, 143. 
Heyman, 429. 
I feysinger, 146. 

Hiatus semilunaris, 5(>7. 587, 588. 
Hinsberg, 329, 338, 340. 
Hiss, 100, 120. 

leucocyte extract. 99. 
History card, Phillips's, 9. 

of patient. 8. 
Hodgkin's disease, 488. 
I [oegye's law, 315. 
Hofnian. 504. 

Hollander, 417. [554. 

Holmes' middle turbinal scissors, 553, 

nasopharyngoscope, 192-3. 

study of hysteria of ear, 405. 
1 [ooper, adenoid forceps, 685. 
I tome, 407. 
Howell, 37. 
Hubby, 102. 
Huber, I rancis, 74. 
Hunt, Ramsey, 58, 111. 115. 
I [{inter sponge holdi r, 680 
I [urd, tonsil separator, 726, 728. 
I [utchinson, 436. 
I futchinson's teeth in congenital syph 

ilis, 117 
I [ydropathic applications, 86. 
Hydrophobia, 478. _ 

aural symptoms in, 178 

laryngeal symptoms in, 478. 
Hydrorrhea, nasal. 649. 



844 



INDEX. 



Hydrotherapy, 80. 
Hyperalgesia of larynx, 787. 
Hyperemia, artificially induced, 97, 98. 
Hyperesthesia acoustica, 52. 

of larynx, 786. 

of pharynx, 574. 
Hyperesthetic rhinitis, 484, 645. 
Hyperkeratosis. See Keratosis. 
Hyperosmia, 644. 

Hyperplasia of lymphoid tissue in naso- 
pharynx, 667. 
Hyperplastic laryngitis, 763. 

pharyngitis, 714. 

tonsillitis, 720. 
Hypertrophic nasopharyngitis. Sec 

Nasopharyngitis. 
Hypertrophy of Luschka's tonsil, 667. 

of middle turbinate, 549, 550. 
Hysteria of ear, 404. 

Holmes's study of, 405. 

Illumination, 4. 
Impacted cerumen, 130. 
Incisure Rivini, 175. 

Santorini, 104. 
Incus, ligaments of, 178. 
Indirect bronchoscopy, 8. 

laryngoscopy, 14. 
Inflammation of membrana tympani, 

167. See also Myringitis. 
Inflation of tympanic cavity, 16. 
Influenza, 475. 

ear and, 475. 

larynx and, 475. 

mouth and throat, 475. 
Infundibulum of frontal sinus, 587. 
Ingals's frontal sinus drainage tube, 
599. 

pilot burr, 598. 
Instruments, sterilization and care of, 

7. 
Insufflation, 90. 
Intracranial complications of purulent 

otitis media, 344-363. 
Intratracheal cannula, 752. 
Intratympanic muscles, 179. 
Intubation, 460. 

feeding after, Casselberrv method, 
464. 

in chronic stenosis of larynx, 463. 

mummy bandage for, 459. 

set, O'Dwyer, 458, 459, 460, 461, 453. 
Irrigation tube, antrum, 579. 
Isandert, 487. 

Jack's mastoid-wound retractor, 231. 
Jackson, 14, 436, 472, 543, 812. 
Jackson's bronchoscopy tubes, 815. 

double-cell battery, 820. 

foreign-body forceps, 818. 

secretion aspirator, 817. 

separable speculum, 817. 



Jackson's tubular speculum, 816. 
turbinectomy scissors, 559, 561. 
Jacobson, 489. 

J an sen, 292, 293, 338, 340, 600, 628. 
Jansen-Neumann operation for puru- 
lent labyrinthitis, 340, 341. 
Jansen's curved needle, 534. 

fibrocartilaginous-wall retractor, 281. 
mastoid-wound retractor, 231. 
maxillary-sinus operation, 584. 
Johnson, 428. 

Jugular bulb, injury to, in radical mas- 
toid operation, 289. 
resection of, in sinus thrombosis, 
360. 
after-treatment, 363. 
difficulties of, 362. 
technique, 360. 
Junker, 154. 

Katz, L., 385. 

Kayser, 701. 

Keloid of auricle, 151. 

Keppler, 221. 

Keratosis of pharynx, 745. 

Kerley, 475, 483. 

Kerrison's chisel forceps, 278. 

Kershner, 166. 

Kessel, 26. 

Kidd, 422. 

Killian, 14, 592, 600, 604,, 606, 619, 651, 

662, 803, 812. 
Killian's bronchoscope, 814 

crotch chisel, 335, 337. 

forceps, 428. 

frontal sinus cannula, 591. 

operation for frontal sinus disease, 
601. 
after-treatment, 605. 
technique. 601. 

packing forceps, 599. 

protector, 602. 

septal chisel, 537. 

split-tube spatula, 813. 

straight-tube spatula, 813. 

submucous resection of nasal sep- 
tum, 529. 

submucous speculum, 534. 

tubular speculum, 777. 

V-shaped chisel, 602. 
Kirschner, 478. 
Kirstein, 812, 813. 
Kirstein's headlight, 14, 814. 
Knight's angular scissors, 543. 
Koenig, 70. 
Koerner's flaps, 146, 294, 295. 

theory of etiology of acute middle- 
ear catarrh, 181. 
Kopetzky, 67, 69, 70, 72, 98, 221, 370. 
K6rner,"71, 181, 215. 221, 256, 280, 307, 
345, 346, 347, 348, 350, 367, 370, 
375, 377, 384, 393, 394, 



INDEX. 



845 



Krause, 426. 

laryngeal forceps, 770. 
Krause-Heryng forceps, 428. 
Krause-Herzog laryngeal forceps, 427. 
Krelschmann, 435. 
Kuhnt, 600. 
Kiimmel, 157, 182, 350. 
Ktister, 280, 581. 
Kiittner, 489. 
Kyle, 512, 515, 516, 517, 746, 774. 

tonsil-crypt knife, 726. 

Labbi, 70. 

Labyrinth, emboli in, 390. 
fistula in, 325, 326. 
fractures through, 45. 
function of, 29. 
hemorrhage into, 390. 
indications for opening, 339. 
injury to, in radical mastoid opera- 
tion, 289. 
invasion of, mechanics and mode of, 

331. 
operations upon, 390. 
otosclerosis of, 385. 
spongification of capsule of, 385. 
vulnerable points in wall of, 329. 
Labyrinthine involvement, disturbances 
of equilibrium in, 312, 338. 
experimental evidence of, 315. 
nystagmus in. 312, 313, 314. 
vertigo in, 312, 313. 
Labyrinthitis, purulent, 312-343. 
clinical picture of, 336. 
course of, 335. 
indications for opening labyrinth in, 

339. 
induced or experimental evidence 

of, 314. 
invasion of labyrinth in. mechanics 
and mode of, 331. 
from blood-vessels. 332. 
from meninges, 333. 
from tympanic cavity, 331. 
operations in. 340. 
Hinsberg, 340. 
Jansen-Neumann, 341. 
Richards, 342. 
pathology, 334. 
prognosis, 338. 
sinusitis and, 337. 
s) mptoms, general, fever, 336. 
nausea and vomiting, 336. 
pain, 33(,. 
referable t'> vestibular apparatus, 
312. 
disturbances of equilibrium, 

312. 33*. 
nystagmus, 312, 313. 314. 
vertigo, 312. 313. 
special, disturbances of co ordi 
nation, 338. 



Labyrinthitis, purulent, symptoms, 
special, facial paralysis, 338. 
impairment of hearing, 337. 
tinnitus aurium, 337. 
tests, experimental, in, 315, 316. 
caloric, 316, 322. 
Ewald's, 315, 
fistula, 316, 325. 
galvanic 316, 327. 
Hoegye's law, 315. 
rotation, 316. 
treatment, 339. 
Lack, 607, 609. 
Lake, 422, 429, 515, 563, 612. 
Lambert, Adrian, 101. 
Lamorier, 581. 
Langenbeck's hoe periosteal elevator, 

229. 
Laryngeal abscess, 755. 

applicator, Phillips's, 7, 665, 767. 
forceps, 427, 770. 
mirror, 13, 14, 15. 
stenosis, cbronic, 463, 773. 
vertigo, 801. 
Laryngectomy, complete, 782, 783. 

partial, 782, 783. 
Laryngismus stridulus. See Spasm of 

glottis. 
Laryngitis, acute infectious. 754. 
due to general infections, 754. 
due to local infections, 754. 
acute edematous, 754. 
diagnosis, 756. 
etiology, 755. 
pathology', 755. 
prognosis, 756. 
symptoms. 755. 
treatment, 756. 
membranous, 759. 

diagnosis, 760. See also Diph- 
theria, 
etiology, 759. 
pathology, 759. 
prognosis, 760. 
symptoms, 760. 
treatment, 760. 
chronic atrophic, 770. See also 
Rhinitis, 
diagnosis, 771. 
etiology, 770. 
pathology, 770. 
prognosis, 771. 

symptoms. 77H 

treatment, 771. 
chronic catarrhal, 763, 765, 

pathology, 7<<^. 

treatment, 7' 6 
. hronic hyperplastic, 763. 

contributing < auses, 763. 

diagnosis, 764 

etiol 763 

prognosis, 764. 



846 



INDEX. 



Laryngitis, chronic hyperplastic, symp- 
toms, 764. 
treatment, 765. 
chronic subglottic, 767. 
pathology, 767. 
prognosis, 767. 
symptoms, 767. 
treatment, 767. 
sicca. See Chronic atrophic, 
simple acute, 748. 

as observed in adults, 748. 
etiology, 748. 
pathology, 748. 
prognosis, 750. 
symptoms, 749. 
treatment, 750. 
as observed in children, 753. 
diagnosis, 753. 
symptoms, 753. 
treatment, 753. 
spasmodic. See Simple acute, 
stridulosa. Sec Simple acute, 
traumatic, 762. 
Laryngofissure. See Thyrotomy. 
Laryngorrhea. See Laryngitis, simple 

acute. 
Laryngoscope, Hays, 755. 
Laryngoscopy, 14. 
direct, 812. 

anesthesia technique, 815. [816. 

with patient in sitting position, 
in dorsal decubitus. 819. 
history of, 812. 
in malignant neoplasms of larynx, 

777. 
suspension, 803. 
Larynx, acute inflammatory diseases of, 
746. 
abscess of, 755. 
adhesions of, syphilitic, 442. 
anatomical points of, 746. \773. 

ankylosis of cricoarytenoid joint, 
chondritis, chronic, 772. 
deformities of, syphilitic, 442, 444. 
diphtheria of, 453. 
erysipelas of, 477. 
examination of, 11, 14. 
foreign bodies in, 774. 
gummata of, 439. 442, 445. 
influenza and, 475. 
lupus of, 430. 

necrosis of syphilitic, 442, 445. 
neoplasms of, 775. 
benign, 775. 
malignant, 778. 
neuroses of. 785. 
motor, 787. 
sensory, 785. 
perichondritis of, acute infectious, 
758. 
chronic, 772. 
syphilitic, 442. 



Larynx, prolapse of ventricle of, 774. 

scars of, syphilitic, 442. 

spasms of, 798. 

stenosis of, 773. 

syphilis of, 445. 

tuberculosis of, 422. 

ulcerations of, syphilitic, 442. 
Lateral sinus, anatomy of, 346. 

surgery of. See Sinus thrombosis, 
thrombosis of, 346. 
Lattrom, A., 419. 
Launois, 182. 
Lautermann, 489. 
Leduc, autoinsufflator, 430. 
Leech, 96. 

artificial, 96, 97. 

real, 96. 
I.e Forte, 436. 

Leland tonsil separator, 725. 
Langenbeck's cold-wire snare, 656. 

operation for sarcoma of nose, 658. 
Leprosy, 480. 

Leptomeningitis, otitic, 367. 
Leucoplakia oris, 448. 

etiology, 448. 

pathology, 448. 

treatment, 448. 
Leukemia, 487. 
Leutert, 70, 71, 364. 
Levy, 418, 428. 
Libman, 44, 76, 77. 7S, 351. 
Life insurance in relation to ear dis- 
eases, 398. 
statistics of, Phillips's, 398. 
Ligation of jugular vein, 100. 
Light, Cooper-Hewitt, 430. 

Finsen, 417, 430. 

reflex, 62, 175, 176. 
Limbeck, 75. 

Lipomata of larynx, 775. 776. 
Lister's sinus forceps, 709. 
Lobule of ear, malformations of, 145. 
Lockard, 428. 

Locomotor ataxia. See Tabes dorsalis. 
Loeb, 610, 616, 617, 621, 705. 
"Lop-ear," 143. 
L6ri, 483. 
Luc, 600, 601, 607. 
Lucae, douche, 80. 

pneumohydromassage, 388. 

pressure-sound, 89, 389. 

tuning-forks, 37. 
Lucas, 101. 

Ludovici's angina, 755. 
Lumbar puncture, 69. 

as a therapeutic measure, 72. 
bacteriologic findings in, 69. 
dangers of, 74. 
diagnostic value of, 69. 
differential diagnosis by means of, 

71. 
needle, 73. 



INDEX. 



847 



Lumbar puncture, position of patient 
in, 73. 
pressure of fluid in, 69. 
syringe, 73. 
technique, 73. 
"Lumpy jaw." See Actinomycosis. 
Lupus erythematosus, 413. 
exulcerans, 412. 
hypertrophicus, 412. 
of auricle, 412. 
of larynx, 430. 
of mouth and pharynx, 421. 
of nose, 414. 
Luschka's tonsil, 661. 
Lynch, 803, 804, 805. 
Lynch's suspension laryngoscopy appa- 
ratus. 803-811." 
table, 805. 

MacCallum, 467, 469. 
Mach, 26. 

Mackentv operation for pinched nose, 
637, 638, 639. 
radiograph of status lymphaticus, 
490-1. 
Mackenzie, 135, 798. 
Mackenzie, G. W., 328. 
Macrotia, 143. 

Goldstein's operation for, 147. 
Macula acoustica, 31, 32. 
Maggots in nose, 643. 
Malm, 70. 
Malaria, 477. 
Malassez, 75. 

Malignant neoplasms and life insur- 
ance, 400. 
Malingering and hemorrhage of ex- 
ternal auditory canal, 141. 
simulated deafness and, 401. 
Chimani-Moos test in, 402. 
Erhard's test in, 402. 
Malleus, 62. 

ligaments of, 178. 
Manasec, 333. 
Mandl's solution, 514. 
Manubrium, landmark of membrana 

tympani, 64. 
Maragliano, tuberculosis antitoxin, 408. 
Margo tympanicus, 175. 
Manna, 488. 

Marmorek, tuberculosis antitoxin, -4ns. 
Martin, 488. 

Mass.i-.' ill" middle car, 88, 89. 

vibratory, 89, 514. 
Masseur, I >elstanche, 388. 
Mastoid antrum, new growths in, 165. 

burrs, Allport's, 283, 284. 
Mastoid operation in infants and young 
children, 242. 
radical, 279. 
Ballance Hap in, 297. 



Mastoid operation, radical, closure of 
persistent postauricular open- 
ings, 303. 

Mosetig-Moorhof method, 304. 

Passow-Trautmann method, 
303. 
closure of postauricular wound, 

301. 
contraindications for, 279. 
dangers and accidents in, 285. 

dislodgment of stapes, 288. 

facial paralysis, 285. 

injury to carotid artery, 289. 

injury to dura, 2S7. 

injury to glenoid fossa, 290. 

injury to jugular bulb, 289. 

injury to labyrinth, 289. 

injury to lateral sinus, Z67. 
hearing and, 306. 
indications for, 279. 
incision in, 280. 
in tuberculosis of aditus, antrum 

or cells, 412. 
Koerher flap, 294. 
life insurance and, 399, 400. 
Panze Hap, 292. 
postoperative treatment. 307. 
precautionary measures in, 298. 
preparation of patient for, 280. 
results of, 305. 
Siebenmann flap, 296. 
Stacke meatal flap, in, 292. 
technique of, 299. 
Thiersch skin-grafts after. 296. 
simple. 223. 225. 
after-treatment, 246, 248. 
bandage in, 247. 

blood el.it method of after treat- 
ment. 247. 
complications <>f wound, 252. 
double, 247. 
instruments for, 227. 
landmarks in, 228. 
operatic e findings in, 243. 
Phillips's complete outfil for, 244. 
postoperative temperature. 250. 
preparation of patient. 225. 
results of, 224. 252. 
technique, 231. 
Mast,, id process, 67, 220, 221. 

inflammation of. See Mastoiditis, 
periostitis, 210. 
primar) acute, 210. 
secondary, 210. 
surgical anatomj of, 
Mast,, i, litis, acute purulent. 213. 

cause, 215. 

, holesteatoma in, 245. 

diagnosis, 218. 

differentii I '- ,) - 

etiology, 214. 

general pathology, 213. 



848 



INDEX. 



Mastoiditis in influenza, 475. 
in measles, 469. 
in scarlatina, 467. 
treatment, 221. 
operative, 221. 

indications for, 221, 222, 223, 224. 
results of, 224, 252. 
preventive, 220. 
Mathieu tonsillotome. 728, 729, 735. 
Maxillary sinus, anatomy of, 566. 
cysts of, 586. 
diseases of, 570. 
empyema of, 572. 
acute, 572. 
chronic, 572. 
diagnosis, 573. 
prognosis, 577. 
skiagraphy in, 577. 
symptoms, 573. 
treatment, 577. 
irrigation, 579. 

operation, Caldwell-Luc, 584. 
radical, 581. 

through canine fossa, 581. 
after-treatment, 585. 
osteomata, 586. 
Mayer's nasal tube-splint, 527. 

pharyngeal curet, 718. 
McBride, 658, 672. 
McCaw, 472. 

McEwen, 370, 376, 384, 758. 
McKenzie tonsillotome, 728, 729, 734. 

uvulotome, 690. 
McKernon, 75, 78, 348. 
indications for exploration of cranial 
cavity in suspected otitic brain 
abscess, 380. 
Measles, ear complications of, 469 
German, 471. 
Koplik's spots in, 470. 
laryngeal complications of, 470. 
mouth and pharynx complications of, 

470. 
nose complications of, 469. 
treatment, local, 470. 
Medicine dropper, Yankauer, 429. 
Membrana basilaris, 29. 
tectoria, 31. 
tympani, 62, 174. 

anomalies of curvature, 63. 
cicatrization of, 65. 
diseases and injuries of, 167. 
ecchymosis of, 63. 
hyperemia of, 63. 
inflammation of, 167. 
landmarks of, 62, 175. 
neoplasms of, 165. 
paracentesis of, 92, 204. 
pars flaccida, 62, 175. 

tensa, 62, 175. 
pathological changes in, 63. 
perforations of, 65, 66. 



Membrana tympani, perforations of, 
diagnostic significance of, in 
chronic purulent otitis media, 
263. 
solution of continuity of, 64. 
traumatic lesions of, 169. 
from direct violence, 169. 
from indirect violence, 170, 171. 
treatment of, 171. 
Meniere, 489. 

Meniere's symptom-complex, 56. 
Meninges, hyperemia of, 393. 
otitic diseases of, 364-373. 
leptomeningitis, 367. 
meningitis purulenta, 367, 368. 
meningitis serosa benigna, 367, 368. 

serosa maligna, 367, 368. 
pachymeningitis externa, 364. 
interna, 366, 
Meningitis. Boenninghaus's classifica- 
tion, 367. 
course, 368. 
diagnosis, 369. 

operation on meninges in, 370. 
pathology, 367. 
prognosis, 370. 
symptoms, 369. 
therapy, 370. 
Meyer, Fritz, 477. 

Meyer, Wilhelm, researches of, 667. 
Me'yjer, 748. 

Mial, turbinal snare, 561, 562. 
Michaels, 485. 

Michaels's postnasal mirror, 13, 14. 
Michel, 746. 

clamp sutures, 248, 302, 726. 
Microtia, 144, 146. 
Miculicz, 812. 

Miculicz-Stoerck hemostat, 727, 732. 
Middle ear, 167. 

auscultation of, 67. 
blood-supply of, 179. 
discharges from, etiologic and diag- 
nostic significance of, 41, 42, 
43. 
diseases of, 167, 181. 

classification of, 181. 
foreign bodies in, 138. 
inflation of, 16. 

introduction of vapors into, 87. 
lymph supply of, 180. 
nerve supply of, 180. 
pneumomassage of, 88. 
surgical anatomy of, 173. 
traumatism of, 45. 
Miller, 770. 
Milligan, 607. 
Millord, 413. 
Mirva, 390. 
Monti, 450. 
Moore, 488. 
Moos, 435. 



INDEX. 



849 



Morepurgo, 488. 

Morf, 390. 

Morgagni, prolapse of ventricle of, 774. 

Morris, 588. 

Moseley tonsil snare, 375, 376, 726. 

Mosher, 522, 825. 

foreign-body forceps, 818. 
safety-pin closure, 819. 
Moure, 437. 
Mouth, mucous patches in, 438. 

tuberculosis of. See Tuberculosis. 
Mouth-breathing, adenoids and, 670. 
chronic atrophic laryngitis and, 770. 
chronic hyperplastic rhinitis and. 504. 
hypertrophied tonsils and, 721. 
Mouth-gag, Denhart's, 674.. 
Much, 365. 

Mucocele, of middle turbinal, 549. 
Mucous patches, 438. 
Mummy bandage for intubation, 459. 
Mumps. See Parotitis. 
Muscles, tympanic, 27. 
Mycelium leptothrix buccalis, 454. 
Mycosis, pharyngeal, differentiated 
from laryngeal diphtheria, 454. 
See also Keratosis. 
Mygind, 415. 
Myles, 723. 

antrum chisel punch, 579. 
cur'et, 583. 
irrigator tube, 579. 
trocar, 576, 579. 
lingual tonsillotome, 736. 
nasal speculum, 12. 
sphenoidal cannula, 626. 
tonsil punch, 726, 730. 
Myringitis, acute, 167. 
diagnosis, 168. 
etiology, 167. 
treatment, 168. 
Myxomata of external auditory me- 
atus, 164. 
of larynx, 775, 776. 
of nose, 651. 
Nasal accessory sinuses, 566. Sec also 
Sinuses. 
non operative treatment, 577. 
Nasal deformities, external, 629. 
broad-bridge nose, 630. 
crooked or twisted nose, 629. 
Hat nose, 630. 
hooked nose, 629. 
partial or total absem • oi 

630. 
pinched nose, 630. 
"pound" nose. 630. 
"saddle" nose, 629. 
treatment, 631. 
external operation, 631, 
intranasal opera! ion, 631, 638. 
paraffin injection, 630. 
Nasal douche, Fowler's, 512. 



Nasal mucosa, acute inflammatory dis- 
eases of, 491. 
polypi, 651. 

septum, anatomy of. 518. 
abscess of, 545. 
adhesions of, 545. 
deformities of. 519. 

deviations and deflections. 520. 
differential diagnosis. 523. 
etiology, 522. 
pathology, 522. 
perforations. 541. 
spurs or crests, 519. 
symptoms, 523. 
treatment, 524. 
hematoma of, 544. 
opi rations upon, 525. 
Asch, 527. 

comparative value of, 536. 
incision, line o\, 531. 
instruments. 533-537. 
removal of septal spurs. 537. 
Roe, 527. 

submucous resection of septum, 
529. 
perforations of, 541. 
prognosis, 543. 
treatment, 543. 
ulcerations, 544. 
Nasofrontal duct, 587. 

Ingal's method for enlarging, 598. 
Nasopharynx, anatomy of, 661. 
foreign bodies in, 685. 
in opl.isms of, 682. 
benign, 682. 
fibromata. 683. 

polypi, 683. See Nasal polypi, 
malignant, 684. 
carcinomata, 684. 
lymphosarcomata, 684. 
sarcomata, 684. 
teratomata, 685. 
Nasopharj ngitis, acut< . 
etiology, 664. 
symptomatology . '>M. 
ip atmei t, 6( I See Acute rhinitis, 
atrophic. 666. 
symptomatology, 666. 
treatment, 666. 
simple chronic, 1 1 I 
etii ' 

pathology, 665. 

treatment, 665. ic rhi 

nitis. 
Nasopl • 

Nephritis, chronic interstitial, ; 
Neumann, 91, 296, 300, 31 
Neural 

Neurasthenia, aural 
Neuroses, nasal, 

from adenoid^. 



850 



INDEX. 



Neuroses, nasal, reflex, 645. 

New growths and chronic purulent 

otitis media, 257. 
Nichols, 38. 
Nitrous oxid gas, ideal anesthetic for 

paracentesis, 93. 
Noguchi test in labyrinthitis accom- 
panying syphilis, 334, 345. 
in syphilis of middle ear, 435. 
Noise-producer, Barany's, 338. 

Phillips's, 338. 
Noma of auricle in typhus fever, 473. 
Nose, deformities of, from syphilis, 
444. Sec also Nasal deformi- 
ties, 
diphtheria of, 452. 
erysipelas of, 476. 
examination of, 11. 
false, 640. 

foreign bodies in, 642. 
furunculosis of, 643. 
neoplasms of, 651. 
benign, 651. 
angiomata, 656. 
enchondromata, 656. 
fibromata, 655. 
myxomata, 651. 
osteomata, 657. 
papillomata, 655. 
malignant, 657. 
carcinomata, 659. 
sarcomata, 657. 
neuroses of, 644. 
parasites in, 643. 
rhinoliths in, 643. 
Nystagmus, 55, 223, 313, 314, 339. 
in cerebellar abscess, 378. 
of vestibular origin, 314. 

O'Dwyer intubation set, 458, 459, 460, 

461. 463. 
Office equipment, 1-7. 
Ollier's operation for sarcoma of nose, 

658. 
Onodi, 628. 

Opsonic index, 99, 409. 
Opsonins, 98. 

Oropharynx, malformations and de- 
formities, 688. 

surgical anatomy of, 686. 
Osier, 422, 423. 
( ►ssicles, function of, 26. 

ligaments of, 178, 179. 

muscles of, 179. 
Ossiculectomy, 268, 272. 

indications for, 273. 

Kerrison chisel forceps in, 278. 

ring curets in, 273. 

results of, 277. 
Osteitis of middle turbinate, 549. 
Osteomata of external auditory me- 
atus, 165. 



Ostium maxillare, 567, 568. 

Ostrum's forward-cutting forceps, 582. 

Otalgia, 56. 

in diphtheria of ear, 451. 
in rheumatic fever, 477. 
Othematomata, 121. 
Otitic vertigo, 54. 

Otitis circumscripta follicularis, 124. 
externa diffusa, 128. 
fungoides, 129. 
keratosa, 130. 
parasitica, 130. 
media, acute purulent, 196-209. 
bacteriology of, 197. 
course, 200. 
diagnosis, 202. 
etiology, 197. 

in epidemic cerebrospinal menin- 
gitis, 476. 
in influenza, 475. 
in lobar pneumonia, 476. 
in measles, 469. 
life insurance and, 400. 
pathology, 196. 
prognosis, 203. 
symptomatology, 200. 
treatment, 203. 

by incision of drum membrane, 
204. 
chronic purulent, 253-278. 
course, 259, 261. 
diagnosis, 262. 

perforations of drum membrane 
an aid to, 263, 264, 265. 
etiology, 258. 
hearing in, 266. 
intracranial complications, 344. 
life insurance and, 400. 
new growths and, 257. 
pathology, 253. 

changes in bone, 256. 
changes in mucous membrane, 
253._ 
prognosis, 265. 
symptoms, 259. 
treatment, 267. 
local therapy, 268. 
ossiculectomy, 272. 
radical mastoid operation, 2()8. 
279. 
neonatorum, 198, 209. 
Otodynia, 58. 
Otomassage, 89, 194. 
( Oomycosis. 129. 
Otopiesis, 53. 
Otorrhea, 258, 259. 

influence of radical mastoid opera- 
tion on, 306. 
Otosclerosis, 385. 
cause, 386. 
diagnosis, 387. 



IXDEX. 



851 



Otosclerosis, etiology, 385. 

from gout, 482. 

in syphilis, 434. 

pathology, 385. 

prognosis, 388. 

treatment, 388. 
Otoscope, 18, 26. 

Siegel, 65, 
Otoscopic examination, 8, 10, 61, 62.- 

obstacles to, 62. 
Oval window, 67. 
Ozena laryngis, 770. 

of syphilitic origin, 440. 

rhinitis, atrophic, and, 508, 510. 

treatment of, Coffin's, 510. 

Pachyderma laryngis, 768. 
symptoms, 768. 
treatment, 769. 
Pachymeningitis externa, 364. 

interna, 367. 
Packer, 477. 
Page, Lafayette, 329. 
Pain, as a general symptom, referable 
to ear and surroundings, 56. 
in Eustachian tube, 57. 
in external auditory meatus, 56. 
in head, 57. 

in mastoid process, 57. 
in neck, 57. 
in pinna, 56. 
in tympanic cavity, 57. 
in tympanic membrane, 57. 
inflammatory, 56. 
neuralgic, 58. 
Palate retractor, 13. 
White's, 14. 
soft, paralysis of, 406. 
Pansinusitis, 574. 
iPanze flap. 146, 292. 
Papillomata of larynx, 775. 
of nose, 655. 
of pharynx, 737 . 
Paracentesis, 92, 204. 
indications for, 205. 
instruments for, 93, 94. 
in acute purulent otitis media, 204. 
preparation of patient for, 92, 93. 
Paracusis, 188. 
loci, 52. 

Willisii, 53, 187. 
Paraffin injection in atrophied tur 
binals, 514. 
cup, (>33. 
in "saddle" nose, 632. 

Geruny method, 632. 
methods of injection, 633. 
Paralysis, facial, of Otitic origin, 309. 
338. 
of larynx, 788. 

central, 789. 
peripheral, 790. 



Paralysis, adductor, 775. 

bilateral abductor. 791. 

complete, of recurrent nerve, 792. 

induced by disease or injury of re- 
current laryngeal. 790. 

induced by disease or injury of supe- 
rior laryngeal, 796. 

of arytenoids, 796. 

of external tensors, 797. 

of internal tensors, 796. 

of pharynx, 742. 

of soft palate, 406. 

of sphincter of epiglottis. 797. 

of velum palati, 742. 743. 
Parasites in nose, 643. 
Paresthesia of larynx, 786. 

of pharvnx, 744. 
Parker, 429, 492, 507. 521). 7 IS, 744. 753, 

757, 759. 763. 
Parosmia following influen i, 475. 
Parotitis, epidemic, 474. 
Passow, 269. 

Passow-Trautmann method, 303. 
Payne, nasal saw, 542. 
Pemphigus of external ear. M^. 
Perceptive apparatus, disease of. 385. 

405. 
Perforations of membrana tympani, 
65, 66. 
aid in diagnosing chronic purulei t 
otitis media, 263, 2(4. 265. 
Perforations of nasal septum, 541. 
cause, 543. 
prognosis, 543. 
treatment. 543. 
Perichondritis, 120. 
of auricle. 120. 
of larynx. 75X, 771. 
Periosteal elevator-.. Don-lass. 22'K 

Langenbeck, 22*1 
Periostitis of mastoid process, 210. 
Peritonsillar abscess, 7<M. 708. 
Peritonsillitis, 704, 7".<. 710. 
Perrin, 44S. 
Pertussis, 474. 

Pharyngitis, acute infectious, 699. 
membranous, 700. 
parenchj matous, 699. 
chronic atrophic, 71''. 
fetid, 72ii. 

simple. 71''. 

chronic hyperplastic, 714. 
granular, 716. 

simple. 714 

• simple acute, 695. 

toxic, 712. 

traumatic, 711. 
Pharyngocele, 688. Sec <;/.<<> Diver 

ticula. 
Pharyngomycosis. Sec Kerat 

Pharj "-' i" • ' '■''' ■ ] ''- ''■■ 

gotomy, subhyoid, 778. 



852 



INDEX. 



Pharynx, asymmetry of, 688, 689. 
dilatation of, 688. 
diverticula of, 688. 
erysipelas of, 476. 
examination of, 14. 
fungoid growths in, 744. 
in influenza, 475. 
in measles, 470. 
inflammations of, acute infectious, 

698. 
inflammations of, chronic, 714. 
neoplasms of, 737 . 
benign, 737. 

adenomata, 738. 
angiomata, 738. 
dermoid cysts, 738. 
fibromata, 737. 
papillomata, 737. 
malignant, 739. 
carcinomata, 740. 
sarcomata, 739. 
neuroses of, 741. 
motor, 741. 
sensory, 743. 
paralysis of. See Neuroses. 
spasmodic affections. See Neuroses. 
Phillips, 78. 

Phillips's complete mastoid outfit, 244-5. 
galvanoca' ,f ery knife, 682. 
headlight, ectric, 4. 
history card, 9. 
laryngeal applicator, 665, 767. 
modification of Bosworth nasal spec- 
ulum, 11. 
noise producer, 338. 
portable operating table, 243. 
tongue depressor, 724. 
treatment room, 1. 
waste-pail, 2. 
Phlebitis in purulent otitis media, 344. 
Physical examination, 8-23. 
Physiology of hearing, 24-33. 
Pierce, 287. 
Pilz, 434. 

Pinna, pain in. 56. 

Pirquet, concerning vaccination in tu- 
berculosis, 408. 
Pitt. 345. 

life-insurance statistics, 388. 
Pityriasis capitis extending to exter- 
nal ear, 117. 
Pneumatic speculum, 22, 23. 
Pneumohydromassage, Lucas, 388. 
Pneumomassage, 88, 89. 
Pneumonia, lobar, 476. 
Podagra. Sec Gout. 
Politzer, 26. 52, 113, 167, 172, 213, 386, 
396. 434, 435, 436, 488. 
acoumeter, 35, 36. 
air-douche bag. 19. 
method of inflation, 16. 
Politzerization, 86, 87. 



Pollen-therapv, 646. 
Polyotia, 142," 146. 

treatment, 149. 
Polypi, aural, 254, 255, 270. 

in mastoid cells and antrum, 165. 

nasal, 651. 

pharyngeal, 683. 
Postauricular openings, persistent, 303. 
Postnasal mirror, Miehaels's, 13,. 14. 
Poulson, life-insurance statistics, 398. 
Poyst, 437. 
Pregnancy, 489. 
Pressure-atrophy in chronic purulent 

otitis media, 256, 257. 
Prevsing, 374. 

Processus uncinatus, 567, 587. 
Prolapse of ventricle of Morgagni, 774. 
Prussack's space, 176, 180. 
Pseudoacousma, 188. 
Psoriasis buccalis, 448. 

of external ear, 117. 
Puberty, 490. 
Pyemia, otitic, 393. 

Quincke, 69, 73. 

Quinsy, 703. 

Quire's foreign-body extractor, 138. 

Radiograph, illustrating status lym- 
phaticus, 490. 

of diseased right mastoid process, 
221. 

of healthy left mastoid process, 221. 

of normal mastoid process, 220. 

mastoid process, 220-1. 

nasal accessory sinuses, 592-4. 

purulent invasion of a sigmoid 
sinus, 348. 

status lymphaticus, 490-1. 
Radiotherapy, 430. 
Radium in tuberculosis of ear, nose, 

and throat, 408, 413. 
.Rae. John B., 312. 
Randall, 345. 

life-insurance statistics, 398. 
Rapke, 384. 

Rarefaction of bone in chronic puru- 
lent otitis media, 256. 
Reflected light, 4. 
Regnier, 693. 
Reid's base line, 372. 
Retractors, mastoid wound, 231. 

Allport's, 231. 

Jack's, 231. 

submucous hand, 535. 
Retropharyngeal abscess, 693. 
Revolving chair, 1. 
Revolving stool, 3. 
Rheumatic fever, 477. 
Rheumatism and pharyngitis, 716. 

and tonsillitis, 706. 
Rhinitis, 491. 



INDEX. 



853 



Rhinitis, acute, due to chemical and 
mechanical causes, 499. 
due to local specific infections, 499. 
atrophic, 508. 

differential diagnosis, 511. 
etiology, 508. 
of syphilitic origin, 440. 
ozena in, 510. 
pathology, 509. 
prognosis, 511. 
symptoms, 509. 
treatment, 512. 
caseosa, 517. 
diphtheritic, 498. 
erysipelatous, 499. 
. general remarks on, 491. 
gonorrheal, 499. 
hyperesthetic, 484, 645. 
hyperplastic, chronic, 503. 
membranous, 498. 
"occupation," 499. 
of acute exanthemata, 498. 
of influenza, 497. 
of specific inflammations, 517. 
purulent, chronic, 515. 
diagnosis, 516. 
etiology, 515. 
symptoms, 516. 
treatment, 516. 
simple acute, 492. 
complications, 493. 
etiology, 492. 
pathology, 493. 
treatment, 494. 
general local, 495. 
prophylactic, 495. 
simple chronic, 501. 
after-treatment, 503. 
diagnosis, 502. 
etiology, 501. 
pathology, 501. 
l>n tgnosis, 502. 
treatment, 502. 
Rhinoliths, (.43. 
Rhinorrhea idiopathica, 649. 

cerebrospinal, 650. 
Rhinoscleroma, 478. 
Rhinoscopy, anterior, (<7?>. 

posterior. 12. 673. 
Richards's, 304, 342. 

curet, 284. 
Richardson, 215, 225, 227, 469, 711. 
headlight, 225. 

headresl for mastoid operation, 225. 
Ricord, 436. 
Rieder, 75. 
Rieman, 27. 

Rhine's hearing test, 39, 192. 
Rob< rtson tonsil scissors, 7-7. 734. 
Roe, 630. 
operation for deformity of septum, 
$.17. 631. 



Roe septum forceps, 525. 

Roosa, 435. 

Rose-cold. Sec Rhinitis hyperesthetica. 

Rosenberg, 448. 

Rosenheim hemostatic forceps, 726. 731. 

Rosenmuller's fossa, 661. 

Ross, 7SS. 790. 

Rotator, Phillips's, 316. 

Rotheln, 470. 

Rouge, operation for sarcoma of nose. 

658. 
Round window, 67. 
Rubella, 471. 
Rubeola, 471. 

Safetv-pin closer, Moshcr, 819. 

Saj ous, 484, 485. 

Sajous' cotton-holding forceps, 816, 820. 

Santi, 700. 

Sarcomata of external ear, 159. 

of larynx, 778. 

of nose, 657. 

serum therapy in, 659. 
Saw, nasal, Bosworth, 541. 

Payne, 542. 
Scarlatina, 467. 

of ear, 467. 

of larynx, 469. 

of nose, 468. 

of oropharynx, 468. 
Scheibe, 182." 

Scheinmann, laryngeal forceps, 770. 
Schmidt, 483. 
Schmidt, Montz, statistics of neoplasms 

of larynx, 775. 
Schulze, 369. 
Schwabach, 390, 435, 487. 

hearing test, 38. 
Schwartze, 67, 71. "7. 205, 221, 270, 387, 

398. 
Scissors, Asch septum, 526, 527. 

Holmes's middle turbinal, 552, 553. 

[ackson's turbinecti >mj . 559, 561. 

Robertson tonsil, 727. 734. 

turbinal, 561. 
Sclerosis of bone in chronic purulent 

otitis media, 256. 
Screw wi >rms in nosi . 6 13. 
Scurvy. 489. 

Sebaceous cj sts of auricle, 152. 
Seborrhea of external ear, 117. 
Semicircular canals, 29, 30. 
Semon, 757. 7X2. 795, 800. 
Semon Rosenbach law, 78 ( 
Septicemia, otitic, 
Septum, nasal, 518, 51 1 
Serum therapy of nos< . 
Shambaugh, 30, 32, 33, 385. 
Sharp's modification ol 

nasal speculum, 12. 
Sheppard, Mo. 
Shrapnell's membrane, 175. 



854 



INDEX. 



Sicord, 70. 

Siebenmann, 167, 170, 174, 386, 390, 451. 

flap, 296. 
Siegel otoscope, 65. 

pneumatic speculum, 22, 23. 
Simpson's sponge tampon, 542. 

test, 535. 
Singers' nodes. Sec Chorditis nodosa. 
Sinus, accessory, nasal, 566. 

anatomical classification, 566. 
ethmoidal, 610. 
frontal, 587. 
maxillary, 566. 
skiagraphy of, 577, 592. 
sphenoidal, 621. 
lateral, anatomy of, 346. . 

injury to, in radical mastoid opera- 
tion, 287. 
thrombosis of, 344. 
thrombosis, anatomical considera- 
tions, 346. 
diagnosis, 355. 
etiology, 347. 
pathology, 349. 
prognosis, 357. 

relative frequency of intracranial 
complications of otitic oirigin, 
345. 
symptoms, 350. 
treatment, 357. 

jugular resection, 360. 

after-treatment, difficulties of, 

362. 
technique, 360. 
Sinusitis, frontal. Sec Inflammation 

of. 
Skiagraphy, 577, 592, 615. 
Skin-graft, Thiersch, 296. 
Sluder's method for removal of faucial 

tonsils, 730-1. 
Small-pox, 474. 
Smith, Ellerv, 160. 
Smith, Harmon, 600, 601. 

paraffin syringe, 632. 
Snare, cold-wire, Langenbeck, 656. 
nasal, Krause, 553. 
tonsil, Moseley, 726. 
turbinal, Mial, 561, 562. 
Solis-Cohen, 449. 
technique for complete laryngotomy, 
783. 
Somers, 485. 

Sound-conducting apparatus, 25. 
Sound-perceiving apparatus, 29. 
Spasmodic laryngeal cough. See Cho- 
rea of larynx. 
Spasms of glottis, 798. 
of larynx, 798. 
of co-ordination, 800. 
Speculum, aural, 10. 
Delstanche, 23. 
electric, 93. 



Speculum, aural, Siegel pneumatic, 22, 
23. 
nasal, 10, 11. 

Allen-Heffermann's, 535. 
Bosworth's, 11, 12. 
Killian's, 329. 
Mvles's, 12. 
Phillips's, 11, 12. 
Sharp's, 11, 12. 
separable, Jackson, 817. 
tubular, 816. 
Sphenoidal sinus, anatomy, patholog- 
ical, 622. 
surgical, 621. 
diseases of, 624. 
empyema of, 625. 
prognosis, 625. 
symptoms, 625. 
treatment, 577, 625. 
surgical, 626. 

external operations, 628. 
perforation of anterior wall, 

627. 
radical operation, 627. 
simple enlargement of os- 
tium, 626. 
Sphygmomanometer, Faught, 486, 487. 

Janeway, 102. 
Spine of Henle, 229, 230. 
Spira, 269. 

Spirocheta pallida, 432. 
Splint, intranasal, 432. 
nasal, vulcanized rubber, 525, 527. 
nasal-tube, Mayer, 527. 
Spokeshave, Berens, 563, 564. 
Sponge, Bernay's, 641. 
holder, Coolidge, 819. 

Hunter, 680. 
tampon, Simpson's, 542. 
tent, Simpson's, 535. 
"Spongy spot" in mastoiditis, 229, 243. 
Spray apparatus, 4. 

De Vilbiss, 4. 
Spray solutions, 5. 

Douglas's formula for, 496. 
for hay fever, 649. 
Spray-tip, Thomson, 5. 
Spurs, septal, 519. 
Stacke, 280, 291, 307. 
meatal flap, 291, 292. 
operation for supernumerary auricle, 
146. 
"Stammering of the cords," 800. 
Stapes, 29. 
dislodgment of, in radical mastoid 

operation, 228. 
ligaments of, 179. 
Stark, 819. 

Status lymphaticus, 490. 
Steel, 643. 
Stein, 392, 482. 
Steinbriigge, 253, 435. 



INDEX. 



855 



Stenosis, congenital, of pharynx, 688. 

laryngeal, 773. 
Sterilizers, 3. 

portable, 245. 
Sticker, 480. 
Stoerck, 426. 
Stohr, 701. 
Stool, revolving, 3. 
Stotzner, 390. 
Straussmann, 701. 
Stricture of external auditory canal. 

See Atresia of. 
Stubb's adenoid curet, 676, 677. 
Submucous resection of nasal septum, 
29, 531. 
of inferior turbinal, 564. 
set, 539. 
Suepfle, 44. 
Sugar, 390. 

Suspension laryngoscopy, 803. 
Suture, clamp, Michel's, 726. 
Synechia? in nares, 565. 
Syphilis, aural, and life insurance, 400. 

Ehrlich's arsenical preparation, "606," 
in, 432. 

of external ear, 432. 

of internal ear, 435. 

of larynx, 437. 

of middle ear, 434. 

of mouth, 434. 

of pharynx, 436. 
Syringe, antitoxin, 456. 

for removal of cerumen, 80. 

postnasal, 512, 513. 
Tabes dorsalis, 488. 
Table, Phillips's, 243. 
Taylor, 309, 311. 
Tegmen tympani, 173. 
Temperature in aural diseases, 60. 
Temporal bone, fracture of, 45. 
Tenaculum, Carter's tonsil, 725, 726. 
Teutlevan, 177. 
Texier, 437. 
Thierfelder, 471. 
Thiersch skin-graft, 296. 
Thiesen, 746. [catarrh, 195. 

Thiosinamin in chronic middle-ear 
Thoma, 75. 
Thomson, J. j., 5. 

protector for adenoid curet, 678. 

tenaculum forceps, 724. 

tongue depressor, 723. 
Thomson, St. Claire, 607, 650, 699. 
Thornwaldt's bursa, 662. 
Throat, examination of, 11. 
Thrombosis, lateral sinus, 344, 346. 
Thrush, 744. 
Thyrotomy, 778, 782. 
Til'ley, 601, 607. 

Tinnitus auriuin, high blood-pressure 
and, 486. 
in anemia, 487. 



Tinnitus aurium, in chronic interstitial 
nephritis, 489. 
in aural hysteria, 404. 
in chronic middle-ear catarrh 188. 
in mumps, 474. 
in neurasthenia, 401. 
in purulent labyrinthitis, 337. 
in purulent otitis media, 260. 
in tabes dorsalis, vibratory massage 

for, 89. 
with nasal obstruction of septal 
origin, 523. 
Tobleitz, 469. 

Tobold, scarifier, 747, 756. 
Tod Hunter, 375, 378, 380. 
Tongue, 687. 

Tongue depressor, Chapin's, 13, 674. 
Phillips's, 724. 
Thomson's, 723. 
Tonsil, capsule of. See Tonsillitis, 
crypt knife, Kyle's, 726. 
cysts of, 733. 
faucial, 686. 
function of, 701. 
hypertrophied, 720. 
indications for removal of, 722. 
knife, Douglas, 726. 
lingual, 667, 687, 735. 
Luschka's, 667. 
portals of infection, 701. 
punch, Myles's, 726, 730. 
scissors, Robertson, 727. 
separators, Hurd's, 726, 728. 

Leland's, 725. 
snare, Moseley, 726. 
tenaculum, Carter's, 725. 
forceps, Thomson's, 724. 
Tonsillectomy, 723. 
Tonsillitis, acute infectious, 701. 
complications, 706. 
diagnosis, 706. 
etiology, 703. 
pathology, 704. 
prognosis, 706. 
symptoms, 705. 
treatment, /<>/. 
after-treatment, 7b). 
general, 707. 
local, 7ns. _ 
prophylactic, 707. 
varieties. See Pathology, 
chronic hyperplastic, 720. 

(li;i-!M»|s. 721. 

i tiology, 720. 
pathology, 71^. 
prognosis, 721. 
symptoms, 721, 
treatment, 721. 
Tonsillotome, lingual, Myles's, 736. 
Mathieu, 728, 7-'", 735. 
Mr Ken/,.-. 728, 729, 734. 
Tonsillotomy, 722, 729. 



856 



INDEX. 



Tonsillotomy, after-treatment, 730. 

See also Adenoids. 
Toynbee, 28, 272, 474. 
Tracheobronchial tree, 822. 
Tracheobronchoscopy, direct. See Lar- 
yngoscopy, 
lower, 824. 
Tracheoscopy, direct. See Laryngos- 
copy. 
Tracheotomy for benign neoplasms of 
larynx, 778. 
in diphtheria, 465. 
tube, Halm's, 782. 
Trachoma of vocal cords. See Chor- 

ditis nodosa. 
Tragus, malformations of, 145, 149. 
Transillumination of frontal sinus, 
592. 
of maxillary- sinus, 574. 
Coakley lamp for, 575. 
Trautmann, 307, 413. 

triangle, 340. 
Treatment room, 1-7. 
Trel.it. 419. 
Triboulet, 477. 

Trocar, antrum, Myles's, 576, 579. 
Troltsch, 280. 
Tuberculosis, 407-431. 
antitoxins and, 408. 
Calmette ophthalmic reaction and, 

408. 
of accessory sinuses, 417. 
of ear, 409. 
of larynx, 422. 
of numth and pharynx, 418. 
of nose, 413. 
opsonic index and, 408. 
radium and, 408. 
tuberculins and, 408. 
vaccination and. 408. 
X-ray and, 408. 
Tuerck's concealed applicator, 768. 
Tumas, 75. 
Tuning-forks, Bezold-Edelmann, 37. 

Lucae, 37. 
Turbinate bones, anatomy of, 546. 
function of, 547. 
hyperplasia, true, 557. 

inflammation of, acute, 556. 
synechia; of, 565. 
hypertrophy of, 503. 
inferior, 556. 

atrophy of, 558. See also Atro- 
phic rhinitis, 
dilatations of, 559. 
reduction of hyperplasia with gal- 

vanocautery, 559, 560. 
submucous resection, 564. 
turbinectomy, 560, 563. 
turbinotomy, 560, 562. 
middle and superior, 549. 
diseases of, 549. 



Turbinate bones, middle and superior, 
diseases of, treatment of, 550. 
enlargement of, 550. 
surgical, 550. 
anesthetic, 551. 
operation, 552. 
preparation of patient, 551. 
removal of entire middle, 553. 
results, 555. 
Turbinectomy, 552, 553, 560. 
Turbinotomy, 552, 560, 562. 
Turner, 607, 668, 672. 
Tympanic cavity, inflation of, 16. 

pain in, 57. 
Tympanic membrane, atrophy of, 67. 
Tympanophony. See Autophony. 
Typhoid fever, 472. 

complications of, in ear, 472. 
larynx, 472, 473. 
mouth, 472. 
nose, 472. 
pharynx, 473. 

vaccine preventive treatment, 473. 
Typhus fever, 473. 
Tyson, 748. 

Ulcerations of septum, 544. 

Umbo, 62, 175, 176. 

Urbantschitsch, 86, 195, 366, 397, 474. 

Uremia, 489. 

Utricle, 3d. 

Uvula, 686, 687. 

adhesions of, 692. 

elongation of, 690. 

malformations, 689. 

rudimentary, 689. 

surgical removal, 690. 

treatment, 690. 

ulcerations, 692. 
Uvulitis, acute, 691. 
Uvulotome, Mckenzie, 690. 

Vaccine therapy, 98. 

Valsalva's method of inflating ear, 16, 

17, 28, 68. 
Vaporizer. Dench middle-ear, 18, 20, 

87. 
Vapors, introduction of, into middle 

ear, 87. 
Varix, lingual, 687, 735, 736. 
Velum palati, unilateral paralysis of, 

742, 743. 
Vertigo, laryngeal, 801. 
otitic, 55. 
vestibular, 312. 
Vestibular apparatus. 312. 
Vestibule of labyrinth. 29, 30. 
Vibratory massage, 89. 
Vincent's angina, 706, 710. 

treatment, 710, 711. 
Virchow, 166. 
Vocal cords, tuberculosis of, 424, 425. 



INDEX. 



857 



Voice, changes in, in adenoids, 670, 671. 
in chronic hyperplastic laryngitis, 

764. 
in tuberculosis of larynx, 423. 
tests for hearing, 34, 35. 
Voss, bruit in sinus thrombosis, 350. 

Wade, 477. 

Wagener's adaptation of the Michel 
clamp suture for tonsillar 
hemorrhage, 727 . 
forceps, 581. 

Waldeyer's ring, 667. 

Walsham, 701. 

Wassermarm test in labyrinthitis ac- 
companying syphilis, 333. 
in lupus of nose, 416. 
in syphilis of middle ear, 435. 

Waste pail, Phillips's, 3. 

Watch test for hearing, 34. 

Water, hot and cold applications, 85. 

Water massage of drum membrane, 83. 

Weber's hearing test, 39. 

Weiss, 469. 

Wertheimer, 73. 

Wet cups for local bloodletting, 96. 

White's palate retractor, 14. 

Whiting, 293. 

Whooping-cough. See Pertussis. 



Widal, 487. 
Wiese, 435. 

Wild's incision, 97, 164. 
Williams, Watson, 488, 702, 752, 774. 
Wittmaack, 391. 
Woakes, 651. 
Wolf, 35. 
Wolfenden, 429. 
Wood, 419, 422, 701, 745. 
Wright, Jonathan, 41, 78, 99, 159, 351, 
419, 432, 652, 701, 702, 703, 780. 

X-rays in epithelioma of auricle, 157. 
in rhinoscleroma, 479. 
in sarcoma, 568. 
in traumatic pharyngitis. 712. 
in tuberculosis, 408, 413, 417. 

Yankauer, medicine dropper, 429. 
periosteum elevator, 536. 
septal curet, 531, 532. 

Zarniko, 510. 

Zaufel, 136. 

Zeroni, 335, 365. 

Ziegler, 375. 

Ziem, 574. 

Ziemssen, 368, 778. 

Zuckerkandl, 568, 570, 571, 572, 587, 623. 



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